Nursing Elites

1. The infant scheduled for reduction of intussusception passes a soft-formed brown stool the day before the procedure. What intervention should the nurse implement?

• A. Instruct the parents that the infant needs to be NPO.
• B. Notify the healthcare provider of the passage of brown stool.
• C. Obtain a stool specimen for laboratory analysis.
• D. Ask the parents about recent changes in the infant's diet.

Correct answer: B

Rationale: Notifying the healthcare provider is crucial when an infant scheduled for intussusception reduction passes a soft-formed brown stool as it may indicate spontaneous reduction of the intussusception. The healthcare provider needs to be informed to assess if the procedure is still necessary or if further evaluation is required. Instructing the parents that the infant needs to be NPO (nothing by mouth) is not the immediate action required in this situation. Obtaining a stool specimen for laboratory analysis is not necessary as the soft-formed brown stool is likely a result of the intussusception spontaneously reducing. Asking about recent changes in the infant's diet is not the most appropriate action when brown stool is passed before the procedure for intussusception reduction.

2. The nurse determines that an infant admitted for surgical repair of an inguinal hernia voids a urinary stream from the ventral surface of the penis. What action should the nurse take?

• A. Document the finding
• B. Palpate scrotum for testicular descent
• C. Assess for bladder distension
• D. Auscultate bowel sounds

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to document the finding. The infant voiding a urinary stream from the ventral surface of the penis suggests hypospadias, a condition where the urethral opening is on the underside of the penis. This finding is crucial information that needs to be documented for further evaluation. Palpating the scrotum for testicular descent, assessing for bladder distension, and auscultating bowel sounds are not appropriate actions based on the presented scenario and do not address the specific concern of the urinary stream location.

3. What intervention should the nurse implement first for a male toddler brought to the emergency center approximately three hours after swallowing tablets from his grandmother's bottle of digoxin (Lanoxin)?

• A. Administer activated charcoal
• B. Prepare gastric lavage
• C. Obtain a 12-lead electrocardiogram
• D. Give IV digoxin immune fab (Digibind)

Correct answer: A

Rationale: Administering activated charcoal is the priority intervention as it binds with digoxin, preventing further absorption in the gastrointestinal tract. This helps reduce the amount of digoxin available for systemic circulation and minimizes its toxic effects. Gastric lavage is no longer recommended due to potential complications and lack of evidence of efficacy. Obtaining an electrocardiogram may help assess the effects of digoxin toxicity, but it is not the initial priority. IV digoxin immune fab (Digibind) is used in severe cases of digoxin toxicity but is not the first-line intervention.

4. The nurse provides information about the human papillomavirus (HPV) vaccine to the mother of a 14-year-old adolescent who came to the clinic this morning complaining of menstrual cramping. Which explanation should the nurse provide to support administering the HPV vaccine to the adolescent at this visit?

• A. Use of protective barriers during sexual activity prevents most strains of HPV infection
• B. Most adolescents are not honest about being sexually active
• C. Not all strains of HPV will be covered if given at a later date
• D. Immunity must be established to prevent future HPV infection and the risk for cervical cancer

Correct answer: D

Rationale: Administering the HPV vaccine at this visit is essential to establish immunity against HPV, thus reducing the risk of HPV infection and cervical cancer. Vaccination is a proactive measure to protect the adolescent's health in the future. Choice A is incorrect because although protective barriers can reduce the risk of HPV transmission, the vaccine provides broader protection. Choice B is incorrect as it makes a generalization about adolescent behavior that is not relevant to vaccination. Choice C is incorrect as it suggests that delaying vaccination would not impact coverage, which is inaccurate as earlier vaccination provides broader protection against HPV strains.

5. Which developmental behavior should the practical nurse identify as normal for a 6-month-old infant?

• A. Rolls over completely.
• B. Creeps on all fours.
• C. Pulls self to a standing position.
• D. Assumes a sitting position independently.

Correct answer: A

Rationale: The correct answer is A: 'Rolls over completely.' By 6 months of age, infants typically achieve the milestone of rolling over completely. This ability demonstrates increasing strength and coordination. Creeping on all fours, pulling self to a standing position, and assuming a sitting position independently are skills that are usually developed at later stages of infancy. Creeping usually occurs around 9-10 months, pulling self to a standing position around 9-12 months, and assuming a sitting position independently around 8 months. Therefore, at 6 months, rolling over completely is the most expected developmental behavior.

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