Nursing Elites

1. A 1-week-old infant has been in the pediatric unit for 18 hours following placement of a spica cast. The nurse observes a respiratory rate of fewer than 24 breaths/min. No other changes are noted. Because the infant is apparently well, the nurse does not report or document the slow respiratory rate. Several hours later, the infant experiences severe respiratory distress and emergency care is necessary. What should be considered if legal action is taken?

• A. Most infants have slow respirations when they are uncomfortable.
• B. The respirations of young infants are irregular, so a drop in rate is unimportant.
• C. Vital signs that are outside the expected parameters are significant and should be documented.
• D. The respiratory tract of young infants is underdeveloped, and their respiratory rate is not significant.

Correct answer: C

Rationale: In this scenario, the correct answer is C. Any vital signs outside the expected range in an infant should be documented and reported, as they may indicate a developing condition that requires prompt attention. Choice A is incorrect because slow respirations in infants should not be dismissed without assessment and documentation. Choice B is incorrect because a drop in respiratory rate in this case was significant and should have been documented. Choice D is incorrect because even though infants have underdeveloped respiratory tracts, any abnormal respiratory rate should be taken seriously and documented for monitoring and intervention if necessary.

2. Before starting kindergarten, the child should receive boosters of which primary immunizations to ensure ongoing protection?

• A. IPV, HepB, Td.
• B. DTaP, HepB, Td.
• C. MMR, DTaP, Hib.
• D. DTaP, IPV, MMR.

Correct answer: D

Rationale: Before starting kindergarten, the child should receive boosters of DTaP, IPV, and MMR. DTaP provides protection against diphtheria, tetanus, and pertussis, IPV protects against polio, and MMR immunization covers measles, mumps, and rubella. These boosters are essential to maintain immunity and protect the child from these diseases as they enter school. Choices A, B, and C are incorrect because they do not include the recommended boosters for kindergarten entry and may leave the child susceptible to certain infections.

3. What behavior does a toddler subjected to prolonged hospitalization with limited parental visits typically exhibit?

• A. Engage in cheerful interactions with staff members
• B. Display indications of sadness throughout the day
• C. Experience excessive crying when parents are not present
• D. Show limited emotional response to the environment

Correct answer: D

Rationale: Toddlers subjected to prolonged hospitalization with limited parental visits usually exhibit a limited emotional response to the environment. This behavior can be a coping mechanism for the child in dealing with the separation from their primary caregivers. The child might not show the same level of engagement or emotional expression as they would if their parents were present. Choices A, B, and C are less likely because the child's emotional response is typically more subdued and withdrawn in such circumstances, rather than being cheerful, consistently sad, or excessively crying.

4. A 1-month-old girl with low-set ears and severe hypotonia has been diagnosed with trisomy 18. Which nursing diagnosis would the nurse identify as most likely?

• A. Interrupted family process related to the child's diagnosis
• B. Deficient knowledge related to the genetic disorder
• C. Grieving related to the child's poor prognosis
• D. Ineffective coping related to the stress of providing care

Correct answer: C

Rationale: The most likely nursing diagnosis for a 1-month-old girl with trisomy 18, characterized by low-set ears and severe hypotonia, is 'Grieving related to the child's poor prognosis.' Trisomy 18 is associated with a poor prognosis, and families often experience grief as they come to terms with the challenges and uncertainties associated with the condition. 'Interrupted family process' may not be as relevant since the primary focus is on the child's condition. 'Deficient knowledge related to the genetic disorder' could be important but may not be the most likely initial concern, as emotional support for the family is crucial at this point. 'Ineffective coping related to the stress of providing care' is a broad diagnosis that does not specifically address the emotional response to the child's prognosis, which is the primary concern in this case.

5. Based on developmental norms for a 5-year-old child, a healthcare professional decides to withhold a scheduled dose of digoxin (Lanoxin) elixir and notify the healthcare provider. Below what apical pulse did the healthcare professional withhold the medication?

• A. 60 beats/min
• B. 70 beats/min
• C. 90 beats/min
• D. 100 beats/min

Correct answer: C

Rationale: For a 5-year-old child, an apical pulse below 90 beats/min is an indicator to withhold digoxin. Digoxin is a medication that affects the heart, and in pediatric patients, monitoring the pulse rate is crucial due to the risk of bradycardia (slow heart rate) as a potential side effect. In this case, an apical pulse of 90 beats/min or lower indicates a heart rate that may be too slow for a child of this age, warranting the withholding of digoxin and prompt notification of the healthcare provider. Choices A, B, and D are not within the critical range specified for withholding digoxin in a 5-year-old child and would not necessitate withholding the medication.

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