Nursing Elites

1. What findings would the nurse consider normal in assessing the anterior fontanel of a neonate?

• A. Closed anterior fontanel
• B. Sunken anterior fontanel
• C. Bulging anterior fontanel
• D. Pulsating anterior fontanel

Correct answer: D

Rationale: The correct answer is D: Pulsating anterior fontanel. The fontanel should feel flat, firm, and well demarcated. Pulsations are frequently visible at the anterior fontanel, which is a normal finding in a neonate. A closed anterior fontanel, as mentioned, is a potential sign of a major abnormality. A sunken or bulging fontanel (when the infant is quiet) may be indicative of distress or a major abnormality. Therefore, options A, B, and C are considered abnormal findings when assessing the anterior fontanel of a neonate.

2. A mother delivers an infant at 30 weeks gestation. The mother asks the nurse for information on nutrition and if formula would be better since the baby is premature. What is the foundation for the response to the mother by the nurse?

• A. Human milk is preferred over other types of nutrition.
• B. Human milk lacks essential nutrients when the infant is preterm.
• C. Commercial infant formulas are preferred over other types of nutrition.
• D. Commercial infant formulas have not been designed to meet the nutritional needs of preterm infants.

Correct answer: A

Rationale: The correct answer is A. Human milk is the preferred food for infants, including preterm infants. It contains essential ingredients necessary for the infant's growth and development. The mother should pump her breasts to provide milk for the infant if the child is receiving enteral feedings. Once the infant can coordinate breathing, sucking, and swallowing, breastfeeding directly is encouraged. Studies have shown that preterm infants fed fortified human milk have better outcomes compared to those fed commercial infant formulas. Commercial infant formulas may not fully meet the unique nutritional needs of preterm infants, leading to potential longer hospital stays. Therefore, human milk is the best choice for feeding premature infants.

3. What information does the nurse include when teaching parents about nonpharmacologic strategies for pain management in children?

• A. May reduce pain perception.
• B. Make pharmacologic strategies unnecessary.
• C. Usually take too long to implement.
• D. Trick children into believing they do not have pain.

Correct answer: A

Rationale: The correct answer is A: 'May reduce pain perception.' When teaching parents about nonpharmacologic strategies for pain management in children, the nurse should include information that these techniques may help reduce pain perception, make the pain more tolerable, decrease anxiety, and enhance the effectiveness of analgesics. It is important to note that nonpharmacologic techniques should be learned before the pain occurs, and it is beneficial to use both pharmacologic and nonpharmacologic measures for pain control. Choice B is incorrect because nonpharmacologic strategies do not make pharmacologic strategies unnecessary but rather complement them. Choice C is incorrect as nonpharmacologic techniques, when properly learned and applied, do not usually take too long to implement. Choice D is incorrect as the goal of nonpharmacologic strategies is not to trick children into believing they do not have pain, but to help them cope with and manage their pain effectively.

4. What is an important intervention in providing a neutral thermal environment for an LBW infant in an incubator?

• A. Use wool blankets.
• B. Avoid using disposable diapers.
• C. Prevent heat loss.
• D. Closely monitor both incubator and rectal temperatures.

Correct answer: C

Rationale: Preventing heat loss in a low birth weight (LBW) infant is crucial in maintaining a neutral thermal environment. The use of cotton blankets is recommended over wool blankets. Avoiding disposable diapers is not directly related to maintaining a neutral thermal environment. While monitoring temperatures is important, the key intervention is preventing heat loss to ensure the infant's survival.

5. Which nursing intervention should be included in the postoperative care of a child following a tonsillectomy?

• A. Encourage the child to blow the nose gently
• B. Notify the physician if mucus is observed in the emesis
• C. Position the child supine in the immediate postoperative period
• D. Avoid giving citrus juice

Correct answer: D

Rationale: The correct answer is D: 'Avoid giving citrus juice.' Citrus juice can irritate the throat after a tonsillectomy, so it should be avoided. Choice A is incorrect because blowing the nose gently is not a recommended intervention following a tonsillectomy. Choice B is incorrect as mucus in emesis is not uncommon postoperatively and does not necessarily require physician notification. Choice C is incorrect as positioning the child supine immediately postoperatively can increase the risk of airway obstruction and should be avoided.

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