Nursing Elites

1. An infant weighed 8 lb at birth and was 18 inches in length. What weight and length should the infant be at 5 months of age?

• A. 12 lb, 20 inches
• B. 14 lb, 21.5 inches
• C. 16 lb, 23 inches
• D. 18 lb, 24.5 inches

Correct answer: C

Rationale: By 5 months, an infant's weight should typically double from birth, and length should increase by approximately 50%.

2. Parents of a preschool child ask the nurse, "Should we set rules for our child as part of a discipline plan?" Which is an accurate response by the nurse?

• A. It is best to delay the punishment if a rule is broken.
• B. The child is too young for rules. At this age, unrestricted freedom is best.
• C. It is best to set the rules and reason with the child when the rules are broken.
• D. Set clear and reasonable rules and expect the same behavior regardless of the circumstances.

Correct answer: D

Rationale: Clear and reasonable rules provide structure and help children understand expectations, promoting consistent behavior and discipline.

3. The nurse is administering the first hepatitis A vaccine to an 18-month-old child. When should the child return to the clinic for the second dose of hepatitis A vaccination?

• A. After 2 months
• B. After 3 months
• C. After 4 months
• D. After 6 months

Correct answer: D

Rationale: The second dose of the hepatitis A vaccine is recommended 6 months after the first dose to ensure full immunity.

4. A 5-year-old has patient-controlled analgesia (PCA) for pain management after abdominal surgery. What information does the nurse include in teaching the parents about the PCA?

• A. The child may not be pain-free.
• B. The parents or nurse may push the button for a bolus if needed.
• C. The pump allows for a continuous basal rate to deliver a constant amount of medication for pain control.
• D. Monitoring is required every 1 to 2 hours to assess patient response.

Correct answer: C

Rationale: The correct answer is C because the PCA pump can be programmed to deliver a continuous basal rate of pain medication to maintain pain control. While the goal of PCA is effective pain relief, it does not guarantee a pain-free state. In the case of a 5-year-old child, the parents or nurse can administer boluses if necessary since the child may not fully comprehend using the PCA button. Monitoring every 1 to 2 hours for patient response is adequate and there is no need for monitoring every 15 minutes, as stated in choice D, unless specific circumstances dictate more frequent monitoring.

5. The nurse is preparing to assess a 10-month-old infant. He is sitting on his father's lap and appears to be afraid of the nurse and of what might happen next. Which initial actions by the nurse should be most appropriate?

• A. Initiate a game of peek-a-boo.
• B. Ask the infant's father to place the infant on the examination table
• C. Talk softly to the infant while taking him from his father
• D. Undress the infant while he is still sitting on his father’s lap

Correct answer: A

Rationale: Engaging the infant in a familiar game like peek-a-boo can help reduce fear and build rapport before starting the assessment.

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