Nursing Elites

1. The nurse finds a 6-month-old infant unresponsive and calls for help. After opening the airway and finding the XXXX, the infant is still not breathing. What action should the nurse take next?

• A. Palpate the femoral pulse and check for regularity.
• B. Deliver cycles of 30 chest compressions and 2 breaths.
• C. Give two breaths that make the chest rise.
• D. Feel the carotid pulse and check for adequate breathing.

Correct answer: C

Rationale: In a scenario where a 6-month-old infant is unresponsive and not breathing after the airway is open, giving two breaths that make the chest rise is the appropriate action. This helps deliver oxygen to the infant's lungs and can help initiate breathing. Chest compressions are not recommended for infants as the first step in resuscitation. Checking pulses like the femoral or carotid pulse is not the priority when an infant is not breathing, as providing oxygen through breaths is essential.

2. The parents of a 2-month-old infant, who is being discharged after treatment for pyloric stenosis, are being educated by the healthcare provider. Which statement by the parents indicates a need for further teaching?

• A. We should feed our baby in an upright position
• B. We should avoid feeding our baby solid foods until at least 6 months of age
• C. We will lay our baby on their stomach to sleep
• D. We will burp our baby frequently during feedings

Correct answer: C

Rationale: The correct answer is C. Placing babies on their stomach to sleep increases the risk of sudden infant death syndrome (SIDS). The safest sleep position for infants is on their back to reduce the risk of SIDS. Teaching parents about safe sleep practices is crucial in preventing potential harm to the infant. Choices A, B, and D are all correct statements that promote the well-being of the infant. Feeding the baby in an upright position helps prevent reflux, delaying solid foods until 6 months of age is recommended for proper growth and development, and burping the baby frequently during feedings helps prevent gas buildup and colic.

3. A 2-week-old female infant is hospitalized for the surgical repair of an umbilical hernia. After returning to the postoperative neonatal unit, her RR and HR have increased during the last hour. Which intervention should the nurse implement?

• A. Notify the healthcare provider of these findings
• B. Administer a PRN analgesic as prescribed
• C. Document the findings in the infant's medical record
• D. Comfort the infant by swaddling and gently rocking

Correct answer: A

Rationale: In a postoperative neonatal setting, an increase in respiratory rate (RR) and heart rate (HR) in an infant could indicate pain or distress. It is crucial for the nurse to notify the healthcare provider promptly to assess the infant's condition and provide appropriate interventions. Prompt communication with the healthcare provider ensures timely evaluation and management of the infant's discomfort or distress, promoting optimal postoperative recovery and comfort. Administering analgesics without healthcare provider assessment could mask underlying issues, documenting findings alone does not address the immediate need for intervention, and comforting may not resolve the underlying cause of increased RR and HR.

4. A 4-year-old child with a history of frequent ear infections is brought to the clinic by the parents who are concerned about the child’s hearing. What is the nurse’s priority action?

• A. Perform a hearing test
• B. Inspect the child’s ears for drainage
• C. Refer the child to an audiologist
• D. Ask the parents about the child’s speech development

Correct answer: B

Rationale: The nurse's priority action should be to inspect the child's ears for drainage. This immediate assessment can provide valuable information about the presence of infection or fluid accumulation, which can directly impact the child's hearing. By identifying any signs of drainage, the nurse can promptly address any current issues affecting the child's ear health and hearing abilities. Performing a hearing test (Choice A) may be necessary but should follow the initial assessment of the ears. Referring the child to an audiologist (Choice C) can be considered later based on the findings. Asking about speech development (Choice D) is important but not the immediate priority compared to assessing for current ear issues.

5. What information should be reinforced with the mother of a child with ringworm (Tinea)?

• A. Ringworm is not contagious.
• B. Tinea infections are indicative of poor hygiene and uncleanliness.
• C. Tinea infections are spread by direct and indirect contact.
• D. Ringworm often subsides spontaneously.

Correct answer: C

Rationale: The correct answer is C. Ringworm, a fungal infection, is highly contagious and can be spread by direct contact with infected individuals or animals and indirectly through contaminated objects. It is important for the mother to understand the modes of transmission to prevent the spread of the infection to others and to take necessary precautions to ensure proper treatment and containment of the condition. Choices A and D are incorrect because ringworm is indeed contagious, and it may not always subside spontaneously. Choice B is misleading as tinea infections are not solely indicative of poor hygiene; they can affect anyone, regardless of personal cleanliness.

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