Nursing Elites

1. The nurse is caring for a 3-day-old girl with Down syndrome whose mother had no prenatal care. What is the priority nursing diagnosis?

• A. Imbalanced nutrition, less than body requirements related to the effects of hypotonia
• B. Deficient knowledge related to the presence of a genetic disorder
• C. Delayed growth and development related to a cognitive impairment
• D. Impaired physical mobility related to poor muscle tone

Correct answer: A

Rationale: The priority nursing diagnosis for a 3-day-old girl with Down syndrome, whose mother had no prenatal care, is imbalanced nutrition, less than body requirements related to the effects of hypotonia. Newborns with Down syndrome often experience feeding difficulties due to hypotonia, which can lead to inadequate nutrition intake. Option B is incorrect because at this age, the infant is not capable of having knowledge deficits related to a genetic disorder. Option C is incorrect as delayed growth and development are not the immediate priority in this scenario. Option D is incorrect as impaired physical mobility is not typically a priority concern for a newborn with Down syndrome.

2. A nurse is caring for an infant born with exstrophy of the bladder. What does the nurse determine is the greatest risk for this infant?

• A. Infection
• B. Dehydration
• C. Urinary retention
• D. Intestinal obstruction

Correct answer: A

Rationale: Infection is the greatest risk for an infant with exstrophy of the bladder due to the exposure of the bladder and surrounding tissues. The bladder mucosa and adjacent tissues being exposed increase the susceptibility to infections. Dehydration (Choice B) is not the primary concern in this condition. Urinary retention (Choice C) is less likely as exstrophy of the bladder usually presents with constant dribbling of urine. Intestinal obstruction (Choice D) is not directly related to exstrophy of the bladder.

3. An infant who had cardiac surgery for a congenital defect is to be discharged. What should the nurse emphasize to the parents regarding administering the prescribed antibiotic?

• A. Give the antibiotic between feedings.
• B. Ensure that the antibiotic is administered as prescribed.
• C. Shake the bottle thoroughly before administering the antibiotic.
• D. Keep the antibiotic in the refrigerator after opening the bottle.

Correct answer: B

Rationale: The correct answer is B: 'Ensure that the antibiotic is administered as prescribed.' It's crucial to stress the importance of following the prescribed antibiotic regimen to prevent infections and promote proper healing after cardiac surgery. Choice A is incorrect because it does not address the fundamental aspect of adherence to the prescription. Choice C is incorrect as shaking the bottle may not be necessary for all antibiotics and is not a critical instruction in this context. Choice D is incorrect as storage instructions are not directly related to the administration of the antibiotic as prescribed, which is the primary concern in this scenario.

4. A child has undergone a tonsillectomy, and a nurse is providing postoperative care. What is an important nursing intervention?

• A. Encouraging deep breathing exercises
• B. Encouraging the child to eat
• C. Administering antibiotics
• D. Applying ice to the throat

Correct answer: C

Rationale: Administering antibiotics is a crucial nursing intervention after a tonsillectomy because it helps prevent infections, which are a common postoperative complication. Encouraging deep breathing exercises (Choice A) is also important for promoting lung expansion and preventing respiratory complications. Encouraging the child to eat (Choice B) may not be appropriate immediately after a tonsillectomy due to the risk of throat irritation and discomfort. Applying ice to the throat (Choice D) is generally not recommended post-tonsillectomy as it may cause vasoconstriction and hinder the healing process.

5. When developing the plan of care for a child with cerebral palsy, which treatment would the nurse expect as least likely?

• A. Skeletal traction
• B. Physical therapy
• C. Orthotics
• D. Occupational therapy

Correct answer: A

Rationale: In caring for a child with cerebral palsy, skeletal traction is least likely to be a part of the treatment plan. Cerebral palsy is a neurological disorder affecting movement and muscle coordination, and skeletal traction, which involves applying a pulling force on a bone to correct alignment, is not a common intervention for this condition. Physical therapy, orthotics, and occupational therapy are more commonly used in the management of cerebral palsy. Physical therapy helps improve mobility and strength, orthotics assist in supporting and aligning the body, and occupational therapy focuses on enhancing daily living skills and independence. Therefore, skeletal traction is the least likely treatment option among the choices provided.

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