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. What is the primary treatment for minimal change nephrotic syndrome?

• A. corticosteroids
• B. antihypertensive agents
• C. long-term diuretics
• D. increased fluids to promote diuresis

Correct answer: A

Rationale: Corticosteroids are the mainstay of treatment for minimal change nephrotic syndrome due to their immunosuppressive effects, which help reduce proteinuria and control the disease progression. Antihypertensive agents are not the primary treatment for this condition and are typically used to manage hypertension that may result from nephrotic syndrome. Long-term diuretics are not indicated in the treatment of minimal change nephrotic syndrome as they do not address the underlying cause. Increasing fluids to promote diuresis is not a recommended treatment for minimal change nephrotic syndrome, as it can exacerbate edema and fluid overload in these patients.

3. Upon assessing a newborn immediately after delivery, you note that the infant is breathing spontaneously and has a heart rate of 90 beats/min. What is the most appropriate initial management for this newborn?

• A. begin positive pressure ventilations
• B. provide blow-by oxygen with oxygen tubing
• C. assess the newborn's skin condition and color
• D. start chest compressions and contact medical control

Correct answer: A

Rationale: A heart rate below 100 beats/min in a newborn indicates the need for positive pressure ventilation to improve oxygenation. Providing positive pressure ventilations helps in assisting the newborn's breathing efforts to ensure adequate oxygenation. Choice B, providing blow-by oxygen, may not be sufficient to address the underlying issue of inadequate breathing. Choice C, assessing the newborn's skin condition and color, is important but not the most immediate action needed for a heart rate below 100 beats/min. Choice D, starting chest compressions, is not indicated as the infant is breathing spontaneously and has a heart rate, albeit lower than normal, which does not warrant chest compressions.

4. The nurse is assessing a 3-year-old boy whose parents brought him to the clinic when they noticed that the right side of his abdomen was swollen. What finding would suggest this child has a neuroblastoma?

• A. The child has a maculopapular rash on his palms.
• B. The parents report that their son is vomiting and not eating well.
• C. The parents report that their son is irritable and not gaining weight.
• D. Auscultation reveals wheezing with diminished lung sounds.

Correct answer: B

Rationale: Vomiting and poor appetite can be symptoms of neuroblastoma, a malignancy that affects the adrenal glands and sympathetic nervous system. A maculopapular rash on the palms (Choice A) is not typically associated with neuroblastoma. Irritability and poor weight gain (Choice C) may be non-specific findings and do not specifically point towards neuroblastoma. Auscultation findings of wheezing with diminished lung sounds (Choice D) are more indicative of respiratory conditions rather than neuroblastoma.

5. What is the priority nursing responsibility when a 3-year-old child in a crib has a clamped jaw and is having a tonic-clonic seizure?

• A. Apply restraints.
• B. Administer oxygen.
• C. Protect the child from self-injury.
• D. Insert a plastic airway in the child’s mouth.

Correct answer: C

Rationale: During a tonic-clonic seizure, the priority nursing responsibility is to protect the child from self-injury. Applying restraints is not recommended during a seizure as it can lead to further harm. Administering oxygen may be necessary after the seizure to support oxygenation, but it is not the priority during the seizure itself. Inserting a plastic airway is also not indicated as the jaw is clamped, and the child should not have anything placed in the mouth during a seizure. Therefore, the correct action is to ensure the child's safety by protecting them from self-injury, preventing harm from uncontrolled movements and potential falls.

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