A nurse is planning care for a client in labor and delivery. Which of the following activities should the nurse plan to demonstrate working at the highest level of their license?
Fetal heart monitoring
Taking specimens to the lab
Performing vaginal delivery
Giving a client bed bath
The Correct Answer is C
A) Fetal heart monitoring:
Nurses are trained to monitor fetal heart rates, interpret patterns, and identify signs of distress, but this task is typically within the scope of a registered nurse's (RN) practice. It may not involve the critical decision-making or advanced skills associated with the highest level of licensure.
B) Taking specimens to the lab:
Taking specimens to the laboratory is a necessary but routine part of care. While it is important for ensuring proper diagnostic testing, it is a lower-level task and does not demonstrate the highest level of nursing practice. This task is often delegated or performed as part of standard nursing duties.
C) Performing vaginal delivery:
Performing a vaginal delivery is a high-level skill that typically requires advanced education, certification, and licensure beyond that of a registered nurse. This is usually performed by a midwife, obstetrician, or other healthcare providers with advanced training and certification. In many settings, a registered nurse may assist with vaginal deliveries but cannot independently perform them unless they have additional certifications (such as Certified Nurse Midwife).
D) Giving a client a bed bath:
While important for patient care and comfort, giving a client a bed bath is a basic nursing task that does not demonstrate working at the highest level of licensure. It is a fundamental nursing activity often carried out by nurses, nursing assistants, or other support staff. The act of providing a bed bath is part of the foundational skill set and does not require advanced knowledge or decision-making that would demonstrate the highest level of practice.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Milia:
Milia are tiny white or yellowish cysts that appear on a newborn's face, particularly on the nose, chin, or forehead. They are caused by the accumulation of keratin under the skin. Milia usually disappear within a few weeks of life and are not related to the pinkish marks described in the question.
B) Telangiectatic nevi (stork bites):
This finding is consistent with telangiectatic nevi, also known as stork bites. These are flat, irregular, pinkish-red marks often found on the forehead, eyelids, and nape of the neck. They are caused by dilated capillaries in the skin and are common in newborns. The marks blanch when pressed and are usually harmless, disappearing within the first 1-2 years of life. This is the correct answer based on the description provided in the question.
C) Nevus flammeus (port wine stain):
A port wine stain is a dark red to purple, flat birthmark caused by capillary malformations. Unlike stork bites, a port wine stain does not blanch when pressed and is typically present for life. It usually appears on the face, neck, or arms, and the coloration remains the same over time.
D) Nevus vasculosus (strawberry mark):
A strawberry mark is a raised, red, and bumpy birthmark that results from proliferation of capillaries. These marks typically appear in the first few weeks of life and grow in size before eventually shrinking and disappearing by the age of 5-10 years. Strawberry marks are not flat, pinkish, or blanchable, making this option unlikely in the scenario described.
Correct Answer is C
Explanation
A) Dry and stimulate newborn with towel:
Drying and stimulating the newborn immediately after birth is a standard practice to prevent heat loss and promote early bonding. This action helps to prevent heat loss through evaporation and stimulates the newborn to breathe. It is an appropriate intervention to reduce the risk of hypothermia, not increase it.
B) Place a hat on the newborn's head:
Placing a hat on the newborn’s head is an appropriate and helpful intervention. Since a significant amount of heat is lost through the head, especially in newborns who have a larger surface area relative to their body mass, keeping the head covered with a hat helps to retain warmth and reduce the risk of hypothermia. This would not place the newborn at risk for hypothermia.
C) Maintain the delivery room temperature at 20° C (68° F):
A delivery room temperature of 20° C (68° F) is on the lower end of the recommended range for newborn care. Newborns are particularly susceptible to heat loss due to their high surface area-to-body weight ratio and immature thermoregulation system. A cooler environment like 20°C increases the risk of hypothermia, as the newborn will lose heat more quickly than it can generate on its own.
D) Place a blanket on top of maternal and newborn:
Placing a blanket over the mother and newborn is an appropriate intervention to prevent heat loss. This promotes warmth by reducing heat loss from the newborn's body surface to the cooler environment. This would not place the newborn at risk for hypothermia; instead, it helps to maintain body temperature.
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