Nursing Elites

1. The nurse observes that a newborn is having problems after birth. What should indicate a tracheoesophageal fistula?

• A. Jitteriness
• B. Meconium ileus
• C. Excessive frothy saliva
• D. Increased need for sleep

Correct answer: C

Rationale: Excessive frothy saliva is a hallmark sign of tracheoesophageal fistula. The abnormal connection between the esophagus and trachea causes difficulty in swallowing, leading to an accumulation of saliva in the mouth. This symptom is crucial for early identification and management of tracheoesophageal fistula. Choices A, B, and D are incorrect as they are not specific indicators of tracheoesophageal fistula.

2. The nurse is interviewing the mother of an infant. The mother reports, "I had a difficult delivery, and my baby was born prematurely." This information should be recorded under which heading?

• A. History
• B. Present illness
• C. Chief complaint
• D. Review of systems

Correct answer: A

Rationale: The history section of the health record includes details about pregnancy, labor, and delivery, as these factors can have significant implications for the child's health.

3. What is a key distinguishing feature of bronchiolitis in infants?

• A. Dry cough
• B. Wheezing
• C. Stridor
• D. Productive cough

Correct answer: B

Rationale: The correct answer is B: Wheezing. Wheezing is a key distinguishing feature of bronchiolitis in infants, typically caused by respiratory syncytial virus (RSV) infection. Bronchiolitis is characterized by inflammation and mucus buildup in the small airways of the lungs, leading to wheezing sounds during breathing. Choices A, C, and D are incorrect because dry cough, stridor, and productive cough are not typical features of bronchiolitis in infants.

4. When auscultating an infant's lungs, the nurse detects diminished breath sounds. What should the nurse interpret this as?

• A. Suggestive of chronic pulmonary disease
• B. Suggestive of impending respiratory failure
• C. An abnormal finding warranting investigation
• D. A normal finding in infants younger than 1 year of age

Correct answer: C

Rationale: Diminished breath sounds in an infant are an abnormal finding and warrant further investigation to rule out conditions like atelectasis or pneumonia.

5. The caregiver asks why the 6-month-old infant needs to have solid foods when breast milk is such a good source of nutrition. What would be the best response by the nurse?

• A. Solid foods, especially iron-fortified cereals, are introduced to meet the infant's increased nutritional needs, including iron, which breast milk alone may not provide adequately.
• B. The extrusion reflex must be developed and feeding solid foods will help the infant to develop this reflex.
• C. Breastfeeding will become painful when the infant gets more teeth, so the infant needs to eat solid foods.
• D. By this age the infant becomes interested in trying new skills.

Correct answer: A

Rationale: The correct response is A. Solid foods, especially iron-fortified cereals, are introduced to meet the infant's increased nutritional needs, including iron, which breast milk alone may not provide adequately. Choice B is incorrect because the extrusion reflex is related to the tongue-thrust reflex, not the nutritional needs of the infant. Choice C is incorrect as breastfeeding does not become painful when the infant gets more teeth, and it is not a reason for introducing solid foods. Choice D is incorrect as the infant's interest in trying new skills is not a primary reason for introducing solid foods at this age.

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