Nursing Elites

1. A new mother calls the nurse stating that she wants to start feeding her 6-month-old child something besides breast milk, but is concerned that the infant is too young to start eating solid foods. How should the nurse respond?

• A. Advise the mother to wait at least another month before starting any solid foods.
• B. Instruct the mother to offer a few spoons of 2 or 3 pureed fruits at each meal.
• C. Reassure the mother that the infant is old enough to eat iron-fortified cereal.
• D. Encourage the mother to schedule a developmental assessment of the infant.

Correct answer: C

Rationale: At 6 months, infants are generally ready to start eating iron-fortified cereals as their iron stores begin to deplete. Introducing iron-fortified cereals at this age helps meet the infant's nutritional needs, particularly for iron, which becomes deficient as the infant's iron reserves diminish. It is a safe and appropriate first food to introduce to infants around 6 months of age, along with continued breastfeeding or formula feeding. Choice A is incorrect because waiting another month is not necessary if the infant is 6 months old. Choice B is incorrect as introducing pureed fruits as the first food may not provide the necessary iron that the infant needs at this stage. Choice D is also incorrect as scheduling a developmental assessment is not indicated solely based on the desire to start solid foods; it is more appropriate to reassure the mother about starting iron-fortified cereal.

2. The healthcare provider is preparing to suture a 10-year-old with a lacerated forehead. Both parents and the 12-year-old sibling are at the child’s bedside. Which instruction best supports the family?

• A. While waiting for the healthcare provider, only one family member may stay with the child.
• B. All family members should leave while the healthcare provider sutures the child’s forehead.
• C. It is best if the sibling goes to the waiting room until the suturing is completed.
• D. Please decide among yourselves who will stay when the healthcare provider begins suturing.

Correct answer: D

Rationale: Choice D is the best instruction as it involves the family in the decision-making process, allowing them to choose who will stay with the child during the suturing procedure. This approach supports the family's comfort and participation in the child's care, promoting a sense of control and family-centered care. Choices A, B, and C do not promote family involvement and may lead to feelings of exclusion or lack of control among the family members.

3. During a woman's first prenatal visit, the nurse reviews her health care record, noting a history of chickenpox as a child and syphilis as a teenager. Which action is most important for the nurse to take?

• A. Obtain blood and urine for prenatal screens.
• B. Schedule prenatal visits to occur monthly.
• C. Explain common complications of pregnancy.
• D. Obtain baseline blood pressure and weight.

Correct answer: A

Rationale: Obtaining blood and urine for prenatal screens is crucial in identifying any potential infections or conditions that may require monitoring throughout the pregnancy. Screening for infections such as syphilis is essential to ensure appropriate management and prevent adverse outcomes. This action helps in early detection and timely intervention, promoting the health and well-being of both the mother and the developing fetus. The other options, while important during prenatal care, are not as critical as obtaining prenatal screens to assess for any existing infections that could impact the pregnancy.

4. Insulin therapy is initiated for a 12-year-old child who is admitted with diabetic ketoacidosis (DKA). Which action is most important for the nurse to include in the child’s plan of care?

• A. Monitor serum glucose for adjustment in the infusion rate of regular insulin (Novolin R).
• B. Determine the child’s compliance schedule for subcutaneous NPH insulin (Humulin N).
• C. Demonstrate to the parents how to program an insulin pen for daily glucose regulation.
• D. Consult with the healthcare provider about the use of insulin detemir (Levemir Flex Pen).

Correct answer: A

Rationale: In managing diabetic ketoacidosis (DKA), monitoring serum glucose levels is crucial to adjust the infusion rate of regular insulin effectively. This helps in controlling blood glucose levels and preventing complications associated with DKA. Close monitoring and adjustments based on glucose levels are essential for the successful management of DKA. Choice B is incorrect as it focuses on a different type of insulin and compliance schedule without addressing the immediate needs of managing DKA. Choice C is not the priority action and involves educating parents on a different method of insulin administration. Choice D is also not the most important action as it suggests consulting with the healthcare provider about a different type of insulin rather than focusing on immediate glucose monitoring for insulin adjustment in DKA management.

5. The LPN/LVN is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse calculates that the woman's next fertile period is

• A. January 14-15.
• B. January 22-23.
• C. January 30-31.
• D. February 6-7.

Correct answer: C

Rationale: To determine the fertile period, subtract 14 days from the length of the woman's menstrual cycle. In this case, 36-14 = 22. Counting forward from the first day of the last menstrual period (January 8), the fertile period falls around January 30-31. This is because ovulation typically occurs approximately 14 days before the start of the next menstrual period, marking the fertile window for conception.

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