For the first 10 or so years of my cardiac nursing career, I was not comfortable interpreting 12-lead electrocardiograms (ECGs). I wanted to be able to decipher them, so I tried to learn but understanding them always seemed unattainable. I took multiple classes with different instructors. I spent a clinical rotation as part of my clinical nurse specialist program focusing on ECG interpretation with a cardiology nurse practitioner, to no avail. I could not tell a left from a right bundle branch block and axis deviation seemed like gibberish. Finally, the instructor for the 12-lead ECG program at my hospital retired, and as the cardiac intensive care unit clinical nurse specialist/educator, I was asked to take over teaching the class. I agreed (with trepidation) and spent months consulting various sources to reeducate myself. Preparing to teach is what it took for me to really learn the concepts of 12-lead ECG.As you prepare for a certification examination, is there a subject area giving you difficulty? What if you tried explaining the concept to someone else? I have noticed a correlation between nurses passing the CCRN examination and becoming preceptors. I make no claim as to causation (it may simply be the timing in one’s career), but it is interesting. I find that teaching any complex pathophysiology or piece of equipment to someone else helps me understand it better. So why not find a novice nurse, a student, or a coworker to teach?The rhythm strip indicates pacemaker failure to capture, and the patient’s heart rate is lower than the set pacemaker rate, which indicates the pacemaker is not initiating the ventricular heartbeats. Increasing pacemaker output (mA) will increase the stimulus to the heart to capture the myocardium and result in a paced rhythm. Once capture is attained, the pacemaker rate can be increased to optimize cardiac output. Decreasing output (A) provides less electrical stimulus to the myocardium and would not solve failure to capture. Sensitivity (mV) is the pacemaker’s ability to detect intracardiac signals. Decreasing sensitivity (C) by raising the mV level would result in less recognition of any intrinsic heart rhythm (undersensing), leading to asynchronous pacing. Because the pacemaker is already firing, switching to asynchronous pacing would not improve the situation. Increasing sensitivity (D) by lowering the mV level would increase recognition of intrinsic heart rhythm and potentially other noncardiac electrical signals (oversensing), causing inhibition of the pacemaker.Repositioning a patient can open the airway and increase the patient’s vital capacity, improving symptoms of dyspnea nonpharmacologically. Administering opioids (A) is a key pharmacological intervention for reducing dyspnea at the end of life and would be appropriate if the nonpharmacological initial intervention was not effective. Administering benzodiazepines (B) provides anxiolysis, but in this case the restlessness is likely caused by dyspnea. Oxygen delivery (C) may help reduce dyspnea in hypoxemic patients but has not shown benefit in nonhypoxemic patients.This patient is displaying signs of shock due to systemic inflammation and fluid loss from acute pancreatitis. Intravenous fluid resuscitation is the priority to restore perfusion. Treating the patient’s pain (A) in acute pancreatitis is important but is a lower priority than addressing the patient’s shock state. Low-dose norepinephrine (B) can increase perfusion pressure, but patients with acute pancreatitis need aggressive volume resuscitation before starting vasopressors. Patients with acute pancreatitis may have decreased serum ionized calcium levels and hypocalcemia should be corrected (D), but volume replacement is the first priority.As an initial action, discussing the situation with a trusted coworker or nurse leader such as a charge nurse provides support for the nurse and helps identify the next best steps. Although requesting a new assignment (A) may be appropriate if removing the nurse from a distressing situation is necessary, it does not solve the problem and this scenario may not be possible or best for the patient. Confronting the family (C) may increase distress for the family and only serve to dissolve a trusting relationship. A better option may be to arrange an interdisciplinary care conference to explore any misunderstandings the family may have. By reflecting on the situation (D) when there is time for meaningful consideration, the nurse can identify the discrepancy in perspective and values and consider what additional actions may be possible.Coughing decreases abdominal wall compliance, resulting in increased bladder pressures and a falsely elevated intra-abdominal pressure measurement. The cause of the restlessness and coughing should be evaluated and relieved through suctioning, sedatives, or another intervention. Once the patient is more relaxed a repeat pressure measurement can be obtained. Calling the physician immediately (B) would be an appropriate step after ensuring an accurate pressure measurement was obtained. An abrupt increase in intra-abdominal pressure warrants immediate follow-up; monitoring the pressure for 4 hours (C) is too long. Elevating the head of the bed (D) may increase the intra-abdominal pressure.The first step in neonatal resuscitation is to stimulate the infant to encourage breathing. Drying the infant with warm blankets is often enough stimulation for the infant to begin breathing. Tactile stimulation is performed after drying the infant by gently rubbing the infant’s back or rubbing the bottoms of the feet. Checking the heart rate (A) is not needed if the infant is not breathing. Chest compressions (B) are performed only if the heart rate is less than 60/min after 30 to 45 seconds of positive pressure ventilation. If the tactile stimulation does not stimulate breathing, then bag/mask or T-piece/mask ventilation (C) should be initiated as the next step in resuscitation of an apneic infant.This type of newborn rash, called transient neonatal pustular melanosis, can be difficult to differentiate from a congenital viral, fungal, or bacterial rash due to the large size of the pustules and the skin exfoliation. The rash is more common in dark-skinned newborns. The rash is transient and has 2 stages, ending in a brown, freckle-appearing lesion on the skin that fades with time without treatment. A rash with large bullous pustules and exfoliation (Staphylococcus scalded skin syndrome) or other S aureus infections (A) would require antibiotics. Erythema toxicum neonatorum is also a newborn rash (B) but has tiny pinpoint pustules with redness surrounding the pustule. Candida infections (C) are usually red, raised skin rashes.Necrotizing enterocolitis presents with thrombocytopenia, lethargy, apnea, bloody stools, emesis, high gastric residual volume, abdominal distension with tenderness, and signs of inflammation or sepsis. Hypotension, rather than hypertension, can occur due to the inflammatory process (B). Hypoglycemia (C) occurs only if feedings are not tolerated for a prolonged period. A low neutrophil or white blood cell count, not a high neutrophil or white blood cell count, is a sign of necrotizing enterocolitis (D).For infants with risk factors for developmental hip dysplasia, such as breech position at delivery, female sex, papoose swaddling method, large birth size, cesarean delivery, and first-born infants, the goal is to diagnose a hip dislocation by 6 to 12 months of age in an otherwise healthy child. An ultrasound at 4 to 6 months is an important adjunct to routine pediatric follow-up examination and poses no risk of radiation to the developing newborn. Triple diapering (A) is not supported by evidence. Radiographs of the bones before 4 to 6 months of age can be difficult to interpret due to cartilage formation of bones at this age (B) and involves an increased risk of radiation compared with other imaging methods. Follow-up (D) is required when any risk factors are present.A subgaleal hemorrhage is a life-threatening complication of a vaginal birth process. Measuring the head circumference is important and will alert caregivers to continued bleeding in the subgaleal space causing head size or occipital-frontal circumference to increase. Hematocrit assessment (A) is also a way to see if there is continued bleeding, but assessments would need to occur more often. There are no pressure dressings (B) suitable to compress a subgaleal bleed. With a subgaleal hemorrhage, blood pressures (D) should be monitored more frequently than every 12 hours in case of continued bleeding.AACN Certification Corporation publishes a study bibliography that identifies the sources from which items are validated. The document may be found in the AACN certification examination handbook. The contributor of each question written for this column has listed the source used in developing each item. Clinical practice should be based on primary sources of evidence when possible; this column will also include secondary sources to help nurses become aware of available resources for certification review.