Nursing Elites

1. A 4-year-old fell from a third-story window and landed on her head. She is semiconscious with slow, irregular breathing and bleeding from her mouth. After performing a jaw-thrust maneuver with simultaneous stabilization of her head, what should you do next?

• A. Suction the oropharynx
• B. Insert a nasopharyngeal airway
• C. Initiate positive pressure ventilations
• D. Administer oxygen via mask

Correct answer: A

Rationale: In this scenario, the patient is experiencing airway compromise due to the fall and potential oropharyngeal obstruction from bleeding. Performing a jaw-thrust maneuver with head stabilization helps maintain the airway patency. The next step should be to suction the oropharynx to clear any blood or secretions, which can obstruct the airway and lead to aspiration. Inserting a nasopharyngeal airway may worsen bleeding or cause further injury to the patient's airway. Initiating positive pressure ventilations can be ineffective if the airway is not cleared first. Administering oxygen via mask is not the immediate priority; ensuring a patent airway by suctioning takes precedence.

2. A parent arrives in the emergency clinic with a 3-month-old baby who says, “My baby stopped breathing for a while.” The infant continues to have difficulty breathing, with prolonged periods of apnea. Which assessment data should alert the nurse to suspect shaken baby syndrome (SBS)?

• A. Birth occurred before 32 weeks’ gestation
• B. Lack of stridor and adventitious breath sounds
• C. Previous episodes of apnea lasting 10 to 15 seconds
• D. Retractions and use of accessory respiratory muscles

Correct answer: D

Rationale: Retractions and the use of accessory respiratory muscles can be signs of respiratory distress, which may indicate trauma such as shaken baby syndrome (SBS). Shaken baby syndrome can result in brain injury and respiratory compromise, leading to breathing difficulties. Choices A, B, and C are less likely to be associated with SBS. Birth before 32 weeks’ gestation is more related to prematurity rather than SBS. The lack of stridor and adventitious breath sounds, as well as previous episodes of apnea lasting 10 to 15 seconds, are not specific indicators of SBS.

3. The caregiver is teaching the mother of a toddler about burn prevention. Which response by the mother indicates a need for further teaching?

• A. We will leave fireworks displays to the professionals.
• B. I will set our water heater at 130 degrees.
• C. All sleepwear should be flame retardant.
• D. The handles of pots on the stove should face inward.

Correct answer: B

Rationale: The correct answer is B. Setting the water heater at 130 degrees is incorrect because water heaters should be set to no higher than 120 degrees to prevent scald burns. Choice A is correct as leaving fireworks displays to professionals reduces the risk of burns. Choice C is also correct as flame-retardant sleepwear reduces the risk of burn injuries. Choice D is correct as keeping pot handles facing inward prevents accidental spills and burns.

4. While performing a visual inspection of a 30-year-old woman in active labor, you can see the umbilical cord at the vaginal opening. After providing high concentration oxygen, what should you do next?

• A. massage the uterus to facilitate delivery of the fetus
• B. relieve pressure from the cord with your gloved fingers
• C. place the mother on her left side and provide rapid transport
• D. elevate the mother's lower extremities and provide immediate transport

Correct answer: B

Rationale: In the scenario described, the priority is to relieve pressure from the umbilical cord protruding from the vaginal opening by gently pushing it back inside using your gloved fingers. This action helps prevent cord compression, maintains blood flow to the fetus, and ensures fetal oxygenation. Massaging the uterus (Choice A) is not appropriate in this situation as it can potentially worsen the cord compression. Placing the mother on her left side and providing rapid transport (Choice C) can be considered after relieving the pressure on the cord. Elevating the mother's lower extremities and providing immediate transport (Choice D) is not the correct approach when dealing with a visible umbilical cord; instead, the focus should be on relieving pressure from the cord to prevent fetal compromise.

5. A 3-year-old child has a sudden onset of respiratory distress. The mother denies any recent illnesses or fever. You should suspect

• A. croup
• B. epiglottitis
• C. lower respiratory infection
• D. foreign body airway obstruction

Correct answer: D

Rationale: In a 3-year-old child presenting with sudden respiratory distress without fever or recent illness, the most likely cause is a foreign body airway obstruction. Foreign body airway obstruction can lead to a sudden onset of respiratory distress as it blocks the air passage. Croup typically presents with a barking cough and stridor, often preceded by a viral illness. Epiglottitis is characterized by high fever, drooling, and a muffled voice. Lower respiratory infections usually present with symptoms such as cough, fever, and chest congestion. Therefore, in this case, the absence of recent illness or fever makes foreign body airway obstruction the most likely cause of the respiratory distress.

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