Nursing Elites

1. What information should be included in the preoperative plan of care for an infant with myelomeningocele?

• A. Positioning the infant supine with a pillow under the buttocks
• B. Covering the sac with saline-soaked nonadhesive gauze
• C. Wrapping the infant snugly in a blanket
• D. Applying a diaper to prevent fecal soiling of the sac

Correct answer: B

Rationale: Covering the sac with saline-soaked nonadhesive gauze is essential in the preoperative care of an infant with myelomeningocele. This practice helps prevent infection and maintains moisture around the sac before surgery, promoting optimal healing outcomes. Positioning the infant supine with a pillow under the buttocks may be uncomfortable and unnecessary. Wrapping the infant snugly in a blanket does not address the specific care needs of the myelomeningocele. Applying a diaper over the sac can increase the risk of infection and should be avoided in this case.

2. When caring for a 2-year-old girl who is wheezing and has difficulty breathing, which interview question would provide the most useful information related to the symptoms of the child?

• A. Inquiring about child safety in the home
• B. Asking about the temperament of the child
• C. Asking about the child's diet
• D. Asking the parents if they smoke in the home

Correct answer: D

Rationale: Asking the parents if they smoke in the home is the most relevant question as exposure to secondhand smoke can exacerbate respiratory symptoms like wheezing and difficulty breathing in children. Smoking indoors can worsen the child's condition and is crucial information for the healthcare provider to assess and address. Inquiring about child safety in the home, asking about the child's temperament, and questioning the child's diet are important aspects of care but are not directly linked to the immediate respiratory symptoms the child is experiencing.

3. After corrective surgery for hypertrophic pyloric stenosis (HPS) is completed, and the infant is returned to the pediatric unit with an IV infusion in place, what is the priority nursing action?

• A. Apply adequate restraints.
• B. Administer a mild sedative.
• C. Assess the IV site for infiltration.
• D. Attach the nasogastric tube to wall suction.

Correct answer: C

Rationale: The priority nursing action after corrective surgery for hypertrophic pyloric stenosis (HPS) is to assess the IV site for infiltration. This is crucial as it ensures proper fluid administration and prevents complications such as phlebitis or infiltration-related tissue damage. Applying restraints (Choice A) would not be appropriate in this situation as it is not related to the immediate post-operative care of an infant with an IV infusion. Administering a mild sedative (Choice B) is not indicated as the primary concern post-surgery is monitoring the IV site and the infant's response to the surgery. Attaching the nasogastric tube to wall suction (Choice D) is not the priority at this time, as assessing the IV site takes precedence to prevent potential complications.

4. A child with a diagnosis of attention-deficit/hyperactivity disorder (ADHD) is being evaluated for medication management. What is an important assessment for the nurse to perform?

• A. Assess the child's sleep patterns
• B. Assess the child's dietary intake
• C. Assess the child's academic performance
• D. Assess the child's behavior at home

Correct answer: B

Rationale: Assessing the child's dietary intake is crucial in managing symptoms and ensuring proper nutrition in children with ADHD. Dietary factors can influence ADHD symptoms. While sleep patterns, academic performance, and behavior at home are important aspects to consider, dietary assessment plays a significant role in the management of ADHD.

5. When picked up by a parent or the nurse, an 8-month-old infant screams and seems to be in pain. After observing this behavior, what should the nurse discuss with the parent?

• A. Accidents and the importance of preventing them
• B. Limiting the infant's playtime with other children in the family
• C. Any other behaviors that the parent may have noticed
• D. Nutrition and specific vitamins recommended for infants

Correct answer: C

Rationale: Discussing any other observed behaviors with the parent is important to identify patterns or potential issues that could be affecting the infant's well-being. By exploring additional behaviors, the nurse can gather more information to assess the infant comprehensively. This approach allows for a more holistic understanding of the infant's health status, rather than focusing solely on the observed behavior of screaming and apparent pain. Options A, B, and D are incorrect as they do not directly address the need to explore other behaviors that may provide insights into the infant's condition and well-being.

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