Nursing Elites

1. What explanation should be given to a parent about the purpose of a tetanus toxoid injection for their child?

• A. Passive immunity is conferred for life.
• B. Long-lasting active immunity is conferred.
• C. Lifelong active natural immunity is conferred.
• D. Passive natural immunity is conferred temporarily.

Correct answer: B

Rationale: The correct answer is B: 'Long-lasting active immunity is conferred.' Tetanus toxoid injection provides long-lasting active immunity by stimulating the body to produce its own antibodies. Choice A is incorrect because tetanus toxoid injection does not provide passive immunity. Choice C is incorrect because the immunity conferred by the vaccine is not natural but artificially induced. Choice D is incorrect as the immunity provided by the tetanus toxoid injection is active, not passive.

2. At 0345, you receive a call for a woman in labor. Upon arriving at the scene, you are greeted by a very anxious man who tells you that his wife is having her baby 'now.' This man escorts you into the living room where a 25-year-old woman is lying on the couch in obvious pain. The woman states that her contractions are occurring every 4 to 5 minutes and lasting approximately 30 seconds each. Which of the following questions would be most appropriate to ask at this point?

• A. Has your bag of waters broken yet?
• B. Have you had regular prenatal care?
• C. At how many weeks gestation are you?
• D. How many other children do you have?

Correct answer: C

Rationale: Asking about the gestational age is crucial in determining the stage of labor and assessing potential complications. This information helps in understanding the progress of labor and making appropriate decisions regarding the management of the delivery process. Choices A, B, and D are not as pertinent at this point in providing immediate care or assessing the situation compared to knowing the gestational age.

3. When the working mother of a toddler is preparing to take her child home after a prolonged hospitalization, she asks the nurse what type of behavior she should expect to be displayed. What is the nurse’s most appropriate description of her child’s probable behavior?

• A. Excessively demanding behavior
• B. Hostile attitude toward the mother
• C. Cheerful, with shallow attachment behaviors
• D. Withdrawn, without emotional ties to the mother

Correct answer: A

Rationale: After a prolonged hospitalization, a toddler may exhibit excessively demanding behavior as they readjust to being home. This behavior can stem from the child feeling insecure or anxious about the changes in their environment. The child may seek extra attention and reassurance during this transition period. Choices B, C, and D are incorrect because hostility, shallowness in attachment, and withdrawal without emotional ties are less likely behaviors to be displayed by a toddler readjusting to home after a hospital stay.

4. An 18-month-old was brought to the emergency department by her mother, who states, 'I think she broke her arm.' The child is sent for a radiograph to confirm the fracture. Additional assessment of the child leads the nurse to suspect possible child abuse. Which type of fracture would the radiograph most likely reveal?

• A. Plastic deformity.
• B. Buckle fracture.
• C. Spiral fracture.
• D. Greenstick fracture.

Correct answer: C

Rationale: A spiral fracture is characterized by a twisting injury, often indicating child abuse due to the mechanism involved. This type of fracture is commonly seen in non-accidental trauma cases. Plastic deformity is not typically seen on radiographs but refers to a change in the shape of a bone without breaking. Buckle fractures are incomplete fractures commonly seen in children due to their softer bones. Greenstick fractures are also incomplete fractures, but they do not typically raise suspicion of child abuse as spiral fractures do.

5. After a child has just returned from surgery for a tracheostomy, what is the priority nursing action?

• A. Suctioning the tracheostomy tube
• B. Changing the tracheostomy dressing
• C. Monitoring respiratory status
• D. Ensuring the tracheostomy ties are secure

Correct answer: A

Rationale: The priority nursing action after a child has undergone tracheostomy surgery is to suction the tracheostomy tube. Suctioning is crucial to maintain a clear airway, remove secretions, and prevent potential airway obstruction, which is essential for the child's respiratory function. Changing the tracheostomy dressing, while important for wound care, does not take precedence over airway clearance. Monitoring respiratory status is vital but comes after ensuring airway patency. Ensuring tracheostomy ties are secure is significant for stabilizing the tube but is not as urgent as maintaining a patent airway through suctioning.

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