Nursing Elites

1. The parents of a young child ask the nurse for suggestions about discipline. When discussing the use of time-outs, which should the nurse include?

• A. Send the child to his or her room if the child has one.
• B. A general rule for length of time is 1 hour per year of age.
• C. Select an area that is safe and nonstimulating, such as a hallway.
• D. If the child cries, refuses, or is more disruptive, try another approach.

Correct answer: C

Rationale: Time-outs should be in a safe, nonstimulating area, with the length typically being 1 minute per year of the child's age, not 1 hour.

2. The mother of a 6-month-old infant has returned to work and is expressing breast milk to be frozen. She asks for directions on how to safely thaw the breast milk in the microwave. What should the nurse recommend?

• A. Heat only 10 oz or more.
• B. Do not thaw or heat breast milk in a microwave oven.
• C. Always leave the bottle top uncovered to allow heat to escape.
• D. Shake the bottle vigorously for at least 30 seconds after heating.

Correct answer: B

Rationale: Thawing or heating breast milk in a microwave is not recommended because it can create hot spots that may burn the infant and destroy essential nutrients.

3. Where would nonpathologic cyanosis normally be present in the newborn shortly after birth?

• A. Feet and hands
• B. Bridge of nose
• C. Circumoral area
• D. Mucous membranes

Correct answer: A

Rationale: Nonpathologic cyanosis in newborns shortly after birth is typically present in the feet and hands, known as acrocyanosis. This is a normal finding due to the immature peripheral circulation in newborns. Cyanosis of the bridge of the nose, circumoral area, and mucous membranes indicates generalized cyanosis, which suggests a potential underlying distress or major abnormality. Therefore, choice A is correct as it describes the expected location for nonpathologic cyanosis in newborns, while choices B, C, and D represent areas associated with abnormal cyanosis.

4. By what age does birth weight usually triple?

• A. 1 year
• B. 1 month
• C. 2 years
• D. 6 months

Correct answer: A

Rationale: The correct answer is A: 1 year. By the age of 1 year, a baby’s birth weight typically triples. This period allows for significant growth and development in infants. Choices B, C, and D are incorrect because birth weight does not usually triple by 1 month, 2 years, or 6 months of age, respectively.

5. An infant requires surgery for repair of a cleft lip. An important priority of the preoperative nursing care is which?

• A. Initiating discharge teaching
• B. Performing baseline physical and behavioral assessment
• C. Observing for allergic reactions to preoperative antibiotics
• D. Determining whether this defect exists in other family members

Correct answer: B

Rationale: Performing a baseline physical and behavioral assessment is crucial to determine the infant's current health status and to identify any potential risks before surgery.

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