Nursing Elites

1. The nurse is admitting a newborn with hypospadias to the nursery. The nurse expects which finding in this newborn?

• A. absence of a urethral opening
• B. penis appears shorter than usual for age
• C. the urethral opening is along the dorsal surface of the penis
• D. the urethral opening is along the ventral surface of the penis

Correct answer: D

Rationale: Hypospadias is a congenital condition where the urethral opening is located along the ventral surface of the penis, not the dorsal surface (Choice C) or absent (Choice A). This leads to the characteristic appearance of a ventrally displaced urethral meatus. The penis may appear normal in size but with the urethral opening positioned abnormally (Choice D), rather than being shorter than usual (Choice B). Therefore, the correct expectation for a newborn with hypospadias is that the urethral opening is along the ventral surface of the penis, making Choice D the correct answer.

2. A newborn is diagnosed with metatarsus adductus. The parents ask the nurse how this occurred. Which response by the nurse would be most appropriate?

• A. This condition is due to a genetic defect in the bones.
• B. It's most likely from how the baby was positioned in utero.
• C. They really don't know what causes this condition.
• D. There is probably an underlying deformity of the baby's hip.

Correct answer: B

Rationale: Metatarsus adductus is a condition characterized by the inward turning of the front part of the foot. It is often caused by the baby's position in the womb, leading to the foot adopting this position. Choice A is incorrect because metatarsus adductus is primarily related to positioning in utero rather than a genetic defect. Choice C is incorrect as there is an understanding of the common cause of this condition. Choice D is incorrect because metatarsus adductus specifically refers to a foot deformity, not a hip deformity.

3. During a health assessment of a school-age child, where should the nurse focus more attention based on the child's developmental level?

• A. Infections
• B. Poisonings
• C. Risk-taking behaviors
• D. Accidents and injuries

Correct answer: D

Rationale: During the school-age period, children are active, curious, and engaged in various physical activities, making them more susceptible to accidents and injuries. This developmental stage is characterized by increased motor skills and exploration, leading to a higher risk of unintentional harm. While infections, poisonings, and risk-taking behaviors are also concerns for school-age children, focusing on preventing and addressing accidents and injuries is essential due to their heightened physical activity and curiosity.

4. A 3-month-old infant has been hospitalized with respiratory syncytial virus (RSV). What is the priority intervention?

• A. Administering an antiviral agent
• B. Clustering care to conserve energy
• C. Offering oral fluids to promote hydration
• D. Providing an antitussive agent when necessary

Correct answer: B

Rationale: The priority intervention for a 3-month-old infant hospitalized with respiratory syncytial virus (RSV) is clustering care to conserve energy. Infants with RSV often struggle to breathe and require rest periods to recover. Clustering care involves organizing nursing activities to allow for rest intervals, reducing the infant's energy expenditure and aiding recovery. Administering antiviral agents is not the primary intervention for RSV since it is a viral infection, and antiviral medications may not be effective against RSV. While offering oral fluids is crucial for hydration, it may not be the priority when the infant is having respiratory difficulties. Providing an antitussive agent when necessary can help with coughing but is not the priority intervention for managing RSV in this scenario.

5. Which is the most appropriate nursing diagnosis for a child with acute glomerulonephritis?

• A. Risk for injury related to malignant process and treatment
• B. Fluid volume deficit related to excessive losses
• C. Fluid volume excess related to decreased plasma filtration
• D. Fluid volume excess related to fluid accumulation in tissues and third spaces

Correct answer: C

Rationale: The most appropriate nursing diagnosis for a child with acute glomerulonephritis is 'Fluid volume excess related to decreased plasma filtration.' Acute glomerulonephritis is characterized by inflammation in the glomeruli, leading to decreased plasma filtration and retention of fluid. This results in fluid volume excess rather than deficit, making choice C the correct answer. Choice A is incorrect because acute glomerulonephritis is not primarily associated with a malignant process. Choice B is incorrect as the condition typically presents with fluid volume excess rather than deficit. Choice D is also incorrect as fluid accumulation in tissues and third spaces is not a typical manifestation of acute glomerulonephritis.

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