Nursing Elites

1. The nurse is discussing development and play activities with the parent of a 2-month-old boy. Which statement by the parent would indicate a correct understanding of the teaching?

• A. I can give my baby a ball of yarn to pull apart or different textured fabrics to feel
• B. I can use a music box and soft mobiles as appropriate play activities for my baby
• C. I should introduce a cup and spoon or push-pull toys for my baby at this age
• D. I do not have to worry about appropriate play activities at this age

Correct answer: B

Rationale: At 2 months, infants are most stimulated by visual and auditory activities, such as a music box or soft mobiles. These activities help in sensory development and are appropriate for this age.

2. Which reflex, present at birth, is elicited by stroking the sole of the infant's foot, resulting in the fanning of the toes?

• A. Babinski
• B. Moro
• C. Sucking
• D. Rooting

Correct answer: A

Rationale: The Babinski reflex is the correct answer. This reflex is characterized by the fanning out of the toes when the sole of the foot is stroked. It is a normal reflex in infants and is typically present at birth, disappearing by around 12 months of age. The Moro reflex, which involves the infant's response to a sudden loss of support or a loud noise, is not related to the fanning of toes. Sucking and rooting reflexes are related to feeding behaviors and are not elicited by stroking the sole of the foot.

3. What term describes the invagination of one segment of bowel within another?

• A. Atresia
• B. Stenosis
• C. Herniation
• D. Intussusception

Correct answer: D

Rationale: Intussusception is the correct answer. It refers to the condition where one segment of the bowel folds into another, leading to an obstruction. Atresia (Choice A) is the absence or abnormal closure of a normal opening or tubular structure. Stenosis (Choice B) is the narrowing of a passage in the body. Herniation (Choice C) is the abnormal protrusion of an organ or tissue through a defect in its surrounding walls. Intussusception is a medical emergency commonly observed in infants and young children and necessitates prompt intervention to prevent severe complications.

4. A mother tells the nurse that she does not want her infant immunized because of the discomfort associated with injections. What should the nurse explain?

• A. This cannot be prevented
• B. Infants do not feel pain as adults do
• C. This is not a good reason for refusing
• D. A topical anesthetic can be applied

Correct answer: D

Rationale: The nurse should explain that a topical anesthetic can be applied to the injection site before the immunization to reduce discomfort.

5. Which physiological acid-base balance complication would be most important for the nurse to assess in a patient with diarrhea?

• A. High serum pH
• B. Normal serum pH
• C. Metabolic alkalosis
• D. Metabolic acidosis

Correct answer: D

Rationale: The correct answer is metabolic acidosis. Diarrhea can lead to the loss of bicarbonate, causing an imbalance in the acid-base status of the body, specifically resulting in metabolic acidosis. High serum pH (choice A) is incorrect as diarrhea-induced bicarbonate loss would lower pH, not increase it. Normal serum pH (choice B) is not the best answer as diarrhea can disrupt the acid-base balance. Metabolic alkalosis (choice C) is an alkaline state, which is less likely to be caused by diarrhea.

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