Nursing Elites

1. What should be included in the nursing plan of care for a 6-month-old infant admitted to the pediatric unit with a diagnosis of respiratory syncytial virus (RSV)?

• A. Place the infant in a warm, dry environment.
• B. Allow parents and siblings to visit.
• C. Maintain standard and contact precautions.
• D. Administer prescribed antibiotics immediately.

Correct answer: C

Rationale: The correct answer is C: Maintain standard and contact precautions. RSV is highly contagious, primarily spread through respiratory secretions. Therefore, it is crucial to implement infection control measures such as standard and contact precautions to prevent the spread of the virus to other patients, staff, and visitors. Choice A is incorrect because warmth and dryness are not specific interventions for RSV; the focus should be on infection control. Choice B may increase the risk of exposing others to RSV, so limiting visitors is recommended. Choice D is unnecessary because RSV is a viral infection, and antibiotics are not effective against viruses.

2. At 0345, you receive a call for a woman in labor. Upon arriving at the scene, you are greeted by a very anxious man who tells you that his wife is having her baby 'now.' This man escorts you into the living room where a 25-year-old woman is lying on the couch in obvious pain. Which of the following statements regarding crowning is true?

• A. Crowning represents the end of the second stage of labor.
• B. Crowning always occurs immediately after the amniotic sac has ruptured.
• C. It is safe to transport the patient during crowning if the hospital is close.
• D. Gentle pressure should be applied to the baby's head during crowning.

Correct answer: D

Rationale: During crowning, it is important to apply gentle pressure to the baby's head. This helps to prevent rapid delivery, which can lead to tearing and other complications for both the mother and the baby. Applying pressure also helps to control the delivery process, ensuring a safer and more controlled birth. Choices A, B, and C are incorrect because crowning does not signify the end of the second stage of labor, does not always occur immediately after the amniotic sac ruptures, and it is not safe to transport the patient during crowning, especially if the hospital is nearby, as rapid delivery can occur.

3. When teaching the parents of a child with a diagnosis of type 1 diabetes mellitus about insulin administration, what should the nurse emphasize?

• A. Rotate injection sites
• B. Administer insulin before meals
• C. Store insulin in the refrigerator
• D. Administer insulin at bedtime

Correct answer: A

Rationale: The correct answer is to rotate injection sites. This practice helps prevent lipodystrophy, a localized loss of fat tissue that can affect insulin absorption. By rotating sites, the child can avoid developing lumps or indentations in the skin where insulin is repeatedly injected. Administering insulin before meals (choice B) may be necessary for certain types of insulin but is not the priority when teaching about insulin administration. Storing insulin in the refrigerator (choice C) is important for maintaining its potency, but it is not the primary emphasis when teaching about insulin administration. Administering insulin at bedtime (choice D) may be necessary based on the child's insulin regimen but is not the primary consideration for teaching injection techniques and site rotation.

4. During an oral cavity assessment of a 6-month-old infant, the parent inquires about which teeth will erupt first. How should the healthcare provider respond?

• A. Incisors
• B. Canines
• C. Upper molars
• D. Lower molars

Correct answer: A

Rationale: Incisors are the teeth that typically erupt first in infants, usually around 6 months of age. These teeth play a crucial role in biting and cutting food. Canines, upper molars, and lower molars are not the primary teeth to erupt in infants. Canines usually erupt after incisors, while molars, whether upper or lower, come in later during the teething process.

5. After a child has just returned from surgery for a tracheostomy, what is the priority nursing action?

• A. Suctioning the tracheostomy tube
• B. Changing the tracheostomy dressing
• C. Monitoring respiratory status
• D. Ensuring the tracheostomy ties are secure

Correct answer: A

Rationale: The priority nursing action after a child has undergone tracheostomy surgery is to suction the tracheostomy tube. Suctioning is crucial to maintain a clear airway, remove secretions, and prevent potential airway obstruction, which is essential for the child's respiratory function. Changing the tracheostomy dressing, while important for wound care, does not take precedence over airway clearance. Monitoring respiratory status is vital but comes after ensuring airway patency. Ensuring tracheostomy ties are secure is significant for stabilizing the tube but is not as urgent as maintaining a patent airway through suctioning.

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