Nursing Elites

1. The parent of a 1-month-old infant voices concern about the infant’s respirations. The parent states the respirations are rapid and irregular. Which information should the nurse provide?

• A. The normal respiratory rate for an infant at this age is between 20 and 30 breaths per minute.
• B. The respirations of a 1-month-old infant are normally irregular and periodically pause.
• C. An infant at this age should have regular respirations.
• D. The irregularity of the infant's respirations is concerning; I will notify the health care provider.

Correct answer: B

Rationale: The correct answer is B. Irregular respirations with periodic pauses are normal in a 1-month-old infant. Choice A is incorrect because the normal respiratory rate for an infant at this age is higher than the range provided. Choice C is incorrect as irregular respirations are expected in infants. Choice D is not appropriate as irregular respirations with periodic pauses are a normal finding in young infants and do not necessarily indicate a concern that requires immediate notification of the healthcare provider.

2. One of the major differences in clinical presentation between Crohn disease (CD) and ulcerative colitis (UC) is that UC is more likely to cause which clinical manifestation?

• A. Pain
• B. Rectal bleeding
• C. Perianal lesions
• D. Growth retardation

Correct answer: B

Rationale: Rectal bleeding is more commonly associated with ulcerative colitis (UC) than with Crohn disease (CD). While both conditions can cause abdominal pain and growth issues, bleeding is a hallmark of UC due to its superficial mucosal inflammation. Perianal lesions are more characteristic of CD, and growth retardation is typically not a direct clinical manifestation of either CD or UC.

3. 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.

4. A 6-month-old infant with Hirschsprung disease is scheduled for a temporary colostomy. What should postoperative teaching to the parents include?

• A. Dilating the stoma
• B. Assessing bowel function
• C. Limitation of physical activities
• D. Measures to prevent prolapse of the rectum

Correct answer: B

Rationale: Postoperative teaching should focus on assessing bowel function to ensure the colostomy is functioning properly. This includes monitoring stool output, color, consistency, and signs of infection or blockage. Choice A, dilating the stoma, is not recommended without healthcare provider guidance, as it can lead to complications. Choice C, limitation of physical activities, may not be as crucial immediately after colostomy creation. Choice D, measures to prevent prolapse of the rectum, is more relevant for conditions like rectal prolapse and not specifically for a colostomy.

5. The nurse is teaching parents about expected language development for their 6-month-old infant. The nurse recognizes the parents understand the teaching if they make which statement?

• A. Our baby should comprehend the word no.
• B. Our baby knows the meaning of saying mama.
• C. Our baby should be able to say three to five words.
• D. Our baby should begin to combine syllables, such as dada.

Correct answer: D

Rationale: At 6 months, infants typically begin to combine syllables like "dada" or "mama," but they do not yet understand the meaning of these words.

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