Nursing Elites

1. A 12-month-old infant has become immunosuppressed during a course of chemotherapy. When preparing the parents for the infant’s discharge, what information should the nurse give concerning the measles, mumps, and rubella (MMR) immunization?

• A. It should not be given until the infant reaches 2 years of age.
• B. Infants who are receiving chemotherapy should not be given these vaccines.
• C. It should be given to protect the infant from contracting any of these diseases.
• D. The parents should discuss this with their healthcare provider at the next visit.

Correct answer: B

Rationale: Live vaccines, like the measles, mumps, and rubella (MMR) vaccine, should not be administered to immunosuppressed infants, such as those undergoing chemotherapy. The weakened immune system of these infants may not be able to handle live vaccines safely, potentially leading to severe complications. Therefore, it is crucial to avoid giving live vaccines like MMR to infants receiving chemotherapy. Choice A is incorrect as delaying the MMR vaccine until the infant reaches 2 years of age is not the main concern in this scenario. Choice C is incorrect because although MMR vaccination is important for disease prevention, it should not be given to immunosuppressed infants. Choice D is incorrect as immediate action is needed to prevent potential harm from live vaccines in immunosuppressed infants.

2. The parents of a child who is scheduled for open-heart surgery ask why their child must be subjected to chest tubes after surgery. What should the nurse consider before responding in language the parents will understand?

• A. They will increase tidal volumes.
• B. Drainage of air and fluid will be facilitated.
• C. They will maintain positive intrapleural pressure.
• D. Pressure on the pericardium and chest wall will be regulated.

Correct answer: B

Rationale: Chest tubes are used to drain air and fluid from the chest cavity to prevent complications such as pneumothorax or cardiac tamponade after surgery. Choice A is incorrect as chest tubes are not used to increase tidal volumes. Choice C is incorrect as chest tubes do not maintain positive intrapleural pressure; instead, they assist in removing excess air or fluid. Choice D is incorrect as chest tubes do not regulate pressure on the pericardium and chest wall; they primarily aid in drainage.

3. A nurse is caring for an infant with a tentative diagnosis of hypertrophic pyloric stenosis (HPS). What is most important for the nurse to assess?

• A. Quality of the cry
• B. Signs of dehydration
• C. Coughing up feedings
• D. Characteristics of the stool

Correct answer: B

Rationale: The correct answer is B: Signs of dehydration. Infants with hypertrophic pyloric stenosis (HPS) are at high risk of dehydration due to frequent vomiting. Assessing for signs of dehydration, such as decreased urine output, dry mucous membranes, and sunken fontanelles, is crucial for early intervention and management. Choices A, C, and D are not the most critical assessments for HPS. The quality of the cry (choice A) may not provide as much relevant information in this case. Coughing up of feedings (choice C) may be a symptom but is not as crucial as assessing for dehydration. Characteristics of the stool (choice D) are important but assessing for signs of dehydration takes precedence due to the immediate risk it poses to the infant's health.

4. A 2-year-old child who was admitted to the hospital for further surgical repair of a clubfoot is standing in the crib, crying. The child refuses to be comforted and calls for the mother. As the nurse approaches the crib to provide morning care, the child screams louder. Knowing that this behavior is typical of the stage of protest, what is the most appropriate nursing intervention?

• A. Use comforting measures while holding the child.
• B. Fill the basin with water and proceed to bathe the child.
• C. Sit by the crib and bathe the child later when the anxiety decreases.
• D. Postpone the bath for a day because a child this upset should not be traumatized further.

Correct answer: C

Rationale: During the stage of protest, children may exhibit distress and cling to familiar figures, resisting interactions with others. The most appropriate nursing intervention is to sit by the crib, offer comfort, and wait until the child's anxiety decreases before proceeding with bathing. This approach allows the child to feel supported and gradually transition to accepting care. Choice A is incorrect because forcing comfort may escalate the child's distress. Choice B is inappropriate as it disregards the child's emotional state and rushes into the bathing procedure. Choice D is not ideal as it suggests delaying care for an extended period, which may not address the child's immediate needs for comfort and hygiene.

5. A parent tells the nurse, “My 9-month-old baby no longer has the same strong grasp that was present at birth and no longer acts startled by loud noises.” How should the nurse explain these changes in behavior?

• A. “I will check these responses before deciding how to proceed.”
• B. “Failure of these responses may be related to a developmental delay.”
• C. “Additional sensory stimulation is needed to aid in the return of these responses.”
• D. “These responses are replaced by voluntary activity at about five months of age.”

Correct answer: D

Rationale: The correct answer is D. The grasp reflex and startle reflex (Moro reflex) are normal in newborns but typically disappear as the infant's nervous system matures and voluntary control develops. At around five months of age, these reflexes are replaced by voluntary movements as part of the normal developmental process. Choices A, B, and C are incorrect. Choice A suggests delaying a decision until further assessment, which is not necessary as the disappearance of these reflexes is a normal part of infant development. Choice B implies a developmental delay, which is not the case as these reflexes naturally disappear with age. Choice C recommending additional sensory stimulation is unnecessary and not the reason for the absence of these reflexes.

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