Nursing Elites

1. The nurse is measuring the frontal occipital circumference (FOC) of a 3-month-old infant, notes that the FOC has increased by 5 cm since birth, and observes that the child’s head appears large in relation to body size. Which action is most important for the nurse to take next?

• A. Measure the infant’s head-to-heel length
• B. Observe the infant for sunsetting eyes
• C. Palpate the anterior fontanel for tension and bulging
• D. Plot the measurement on the infant’s growth chart

Correct answer: C

Rationale: Palpating the anterior fontanel for tension and bulging is essential to assess for increased intracranial pressure, which could be indicated by the enlarged head circumference. This assessment can help identify potential neurological issues that need prompt attention.

2. A 6-week-old infant diagnosed with pyloric stenosis has recently developed projectile vomiting. Which assessment finding indicates to the nurse that the infant is becoming dehydrated?

• A. Weak cry without tears.
• B. Bulging fontanel.
• C. Visible peristaltic wave.
• D. Palpable mass in the right upper quadrant.

Correct answer: A

Rationale: In infants, a weak cry without tears is a classic sign of dehydration. Tears are produced by the lacrimal glands, and reduced tear production is a result of dehydration. This assessment finding should alert the nurse to the infant's dehydration status, requiring prompt intervention to prevent further complications.

3. During an examination for possible cryptorchidism in an infant, what technique should be used?

• A. Place the infant in a warm room and use a calm approach.
• B. Hold the scrotum and palpate gently.
• C. Cleanse the penis with an antiseptic-soaked pad.
• D. Position the infant in a warm room to prevent muscle contraction.

Correct answer: D

Rationale: When examining an infant for cryptorchidism, it is important to position the infant in a warm room to prevent muscle contraction, which could cause the testes to retract. Placing the infant in a side-lying position may not be necessary for this specific examination. Holding the penis or retracting the foreskin is not relevant to the assessment for cryptorchidism. Cleansing the penis with an antiseptic pad is not indicated for this examination.

4. A woman at 36-weeks' gestation who is Rh negative is admitted to labor and delivery reporting abdominal cramping. She is placed on strict bedrest, and the fetal heart rate and contraction pattern are monitored with an external fetal monitor. The nurse notes a large amount of bright red vaginal bleeding. Which nursing intervention has the highest priority?

• A. Perform a sterile vaginal examination to determine dilatation.
• B. Determine fetal position by performing Leopold maneuvers.
• C. Assess the fetal heart rate and client's contraction pattern.
• D. Confirm Rh and Coombs status for Rho(D) immunoglobulin administration.

Correct answer: C

Rationale: The highest priority nursing intervention in this scenario is to assess the fetal heart rate and the client's contraction pattern. The presence of a large amount of bright red vaginal bleeding in a woman at 36-weeks' gestation who is Rh negative raises concerns about the well-being of the fetus. Monitoring the fetal heart rate and contraction pattern will provide crucial information about fetal status and help determine the appropriate course of action to ensure the safety and health of both the mother and the baby.

5. A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client’s nursing care plan?

• A. Keep airway equipment at the bedside.
• B. Allow liberal family visitation.
• C. Monitor blood pressure, pulse, and respirations q4h.
• D. Assess temperature q1h.

Correct answer: A

Rationale: In a client with eclampsia, the priority intervention is to keep airway equipment at the bedside to manage potential convulsions effectively. This proactive measure is essential to ensure rapid response and intervention in case of convulsions, which can occur in clients with eclampsia.

Similar Questions