Nursing Elites

1. A health care provider prescribes feedings of 1 to 2 oz Pedialyte every 3 hours and to advance to 1/2 strength Similac with iron as tolerated postoperatively for an infant who had a pyloromyotomy. The nurse should decide to advance the feeding if which occurs?

• A. The infant's IV line has infiltrated.
• B. The infant has not voided since surgery.
• C. The infant's mother states the infant is tolerating the feeding okay.
• D. The infant is taking the Pedialyte without vomiting or distention.

Correct answer: D

Rationale: The decision to advance feedings after a pyloromyotomy is based on the infant's ability to tolerate the current feedings without vomiting or abdominal distention. Ensuring the infant can keep down Pedialyte is the key indicator for moving to the next stage of feeding. Choices A, B, and C are incorrect because they do not directly relate to the infant's ability to tolerate the feeding. An infiltrated IV line, lack of voiding, or the mother's statement do not provide direct information on the infant's tolerance to the feeding, unlike the absence of vomiting and distention.

2. Which muscle is contraindicated for the administration of immunizations in infants and young children?

• A. Deltoid
• B. Dorsogluteal
• C. Ventrogluteal
• D. Anterolateral thigh

Correct answer: B

Rationale: The dorsogluteal muscle is contraindicated for immunizations in infants and young children due to the risk of injury to the sciatic nerve. The anterolateral thigh is the preferred site.

3. The nurse is preparing to admit a child to the hospital with a diagnosis of acute poststreptococcal glomerulonephritis. The nurse understands that the peak age at onset for this disease is what?

• A. 2 to 4 years
• B. 5 to 7 years
• C. 8 to 10 years
• D. 11 to 13 years

Correct answer: B

Rationale: The peak age for the onset of acute poststreptococcal glomerulonephritis is typically between 5 and 7 years old. This age group is most affected due to the higher incidence of streptococcal infections in school-aged children, which can lead to this renal complication.

4. What is the recommended position for a child with epiglottitis to ease breathing?

• A. Supine
• B. Prone
• C. Tripod
• D. Semi-Fowler’s

Correct answer: C

Rationale: The correct answer is C, 'Tripod.' In children with epiglottitis, the tripod position is recommended to help open the airway and ease breathing. This position involves the child sitting upright, leaning forward, and supporting themselves with their hands on their knees or another surface. This posture helps improve air entry into the lungs by maximizing the space for breathing. Choices A (Supine), B (Prone), and D (Semi-Fowler’s) are incorrect. Placing a child with epiglottitis in the supine position may further obstruct the airway, while the prone position and semi-Fowler’s position do not facilitate optimal air exchange in these cases.

5. When assessing an infant with intussusception, what type of stool would the nurse expect to find?

• A. Soft, seedy stool
• B. Currant-jelly stool
• C. Ribbon-like stool
• D. Soft and pasty stool

Correct answer: B

Rationale: The correct answer is B: Currant-jelly stool. This type of stool, which is red and mucous-like, is a classic sign of intussusception in infants. Choice A (Soft, seedy stool) is incorrect as it does not specifically describe the characteristic stool associated with intussusception. Choice C (Ribbon-like stool) is incorrect; ribbon-like stool may be seen in conditions like colon cancer, not intussusception. Choice D (Soft and pasty stool) is also incorrect as it does not match the typical stool finding in intussusception.

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