Nursing Elites

1. A child with a fever is prescribed acetaminophen. What should the caregiver teach the parents about administering this medication?

• A. Administer the medication with food
• B. Measure the dose with a household spoon
• C. Measure the dose with a proper measuring device
• D. Administer the medication only when the child has a high fever

Correct answer: C

Rationale: The correct answer is to measure the dose with a proper measuring device. Using a household spoon can lead to inaccurate dosing, which can be dangerous. Administering the medication with food or only when the child has a high fever are not the essential instructions related to the safe and effective administration of acetaminophen.

2. A 13-year-old girl tells the nurse at the pediatric clinic that she took a pregnancy test and it was positive. She adds that her grandfather, with whom she, her younger sisters, and her mother live, has repeatedly molested her for the past 3 years. When the nurse asks the girl if she has told this to anyone, she replies, 'Yes, but my mother doesn’t believe me.' Legally, who should the nurse notify?

• A. Police regarding a possible sex crime
• B. Healthcare provider to confirm the pregnancy
• C. Child Protective Services for immediate intervention
• D. Girl’s mother about the positive pregnancy test result

Correct answer: C

Rationale: In this scenario, the nurse should notify Child Protective Services for immediate intervention. The girl disclosed ongoing sexual abuse by her grandfather, which is a serious concern requiring immediate protection and intervention by the appropriate authorities. Child Protective Services are trained to handle cases of child abuse and neglect, ensuring the safety and well-being of the child. While notifying the police about a possible sex crime is crucial, Child Protective Services should be the first point of contact in cases of suspected child abuse due to their specialized role. Confirming the pregnancy through a healthcare provider is not the priority at this moment, as ensuring the safety of the child is paramount. Informing the girl's mother about the positive test result is not appropriate given the lack of belief in the abuse disclosure and the potential risk to the child's safety.

3. After clearing the airway of a newborn who is not in distress, what is the most important action for you to take?

• A. Apply free-flow oxygen
• B. Clamp and cut the cord
• C. Keep the newborn warm
• D. Obtain an APGAR score

Correct answer: C

Rationale: Keeping the newborn warm is crucial as newborns are at high risk of hypothermia due to their large body surface area and limited subcutaneous fat. Hypothermia can lead to complications such as respiratory distress, hypoglycemia, and metabolic acidosis. Providing warmth helps maintain the newborn's body temperature and supports physiological processes, promoting overall well-being. Applying free-flow oxygen is not necessary if the newborn is not in distress. Clamping and cutting the cord can be done after addressing the immediate need for warmth. Obtaining an APGAR score is important for assessing the newborn's overall condition but ensuring warmth takes precedence to prevent complications related to hypothermia.

4. The nurse is implementing care for a school-age child admitted to the pediatric intensive care unit with diabetic ketoacidosis (DKA). Which prescribed intervention should the nurse implement first?

• A. Begin 0.9% saline solution intravenously as prescribed
• B. Administer regular insulin intravenously as prescribed
• C. Place child on a cardiac monitor
• D. Place child on a pulse oximetry monitor

Correct answer: A

Rationale: Initiating intravenous saline solution is the initial priority in managing diabetic ketoacidosis to address dehydration and electrolyte imbalances. Administering insulin without addressing dehydration first can lead to potential complications. While monitoring cardiac status and oxygen saturation are important, addressing the fluid and electrolyte imbalances takes precedence in the management of DKA.

5. During a physical examination of an infant with Down syndrome, what anomaly should the healthcare provider assess the child for?

• A. Bulging fontanels
• B. Stiff lower extremities
• C. Abnormal heart sounds
• D. Unusual pupillary reactions

Correct answer: C

Rationale: Infants with Down syndrome are at increased risk of congenital heart defects. Therefore, assessing for abnormal heart sounds is crucial during the physical examination. Bulging fontanels are not typically associated with Down syndrome and may indicate increased intracranial pressure. Stiff lower extremities are not a common finding in Down syndrome and may suggest other musculoskeletal issues. Unusual pupillary reactions are not typically linked to Down syndrome and may be indicative of neurological problems instead.

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