Nursing Elites

1. What is the priority assessment for a nurse when caring for an infant suspected of having necrotizing enterocolitis (NEC)?

• A. Hold feedings.
• B. Check gastric residuals before feedings.
• C. Take rectal temperature.
• D. Closely monitor abdominal distention.

Correct answer: D

Rationale: The correct answer is D: Closely monitor abdominal distention. Monitoring the abdomen for signs of distention is crucial in the early detection of necrotizing enterocolitis (NEC). In NEC, the bowel wall is edematous and breaking down, leading to abdominal distention. Holding feedings is important in the management of NEC, as feedings may need to be stopped temporarily. Checking gastric residuals before feedings helps in assessing the infant's tolerance to feedings. Taking rectal temperatures is contraindicated in NEC as it can lead to the perforation of the bowel.

2. The nurse is caring for an infant who had surgical repair of a tracheoesophageal fistula 24 hours ago. Gastrostomy feedings have not been started. What do nursing actions related to the gastrostomy tube include?

• A. Keep the tube clamped.
• B. Suction the tube as needed.
• C. Leave the tube open to gravity drainage.
• D. Secure the tube with tape.

Correct answer: C

Rationale: Leaving the gastrostomy tube open to gravity drainage prevents the accumulation of air and fluids, reducing the risk of complications such as vomiting or aspiration in the immediate postoperative period. Keeping the tube clamped or suctioning it can lead to pressure buildup, increasing the risk of complications. Securing the tube with tape is important but not the primary action related to the gastrostomy tube in this case.

3. What pathologic process is believed to be responsible for the development of postinfectious glomerulonephritis?

• A. Infarction of renal vessels
• B. Immune complex formation and glomerular deposition
• C. Bacterial endotoxin deposition on and destruction of glomeruli
• D. Embolization of glomeruli by bacteria and fibrin from endocardial vegetation

Correct answer: B

Rationale: Postinfectious glomerulonephritis is typically caused by immune complex deposition in the glomeruli following a streptococcal infection. This immune response leads to inflammation and impaired kidney function.

4. What should the nurse explain about ringworm?

• A. It is not contagious
• B. It is a sign of uncleanliness
• C. It is expected to resolve spontaneously
• D. It is spread by both direct and indirect contact

Correct answer: D

Rationale: Ringworm is a fungal infection that spreads through direct and indirect contact. Good hygiene practices can help prevent its spread.

5. What does the American Academy of Pediatrics recommend as the best form of infant nutrition?

• A. Exclusive breastfeeding until 1 year of age
• B. Exclusive breastfeeding until 6 months of age
• C. Commercially prepared infant formula until 1 year of age
• D. Commercially prepared infant formula until 4 to 6 months of age

Correct answer: A

Rationale: The American Academy of Pediatrics advocates for exclusive breastfeeding until 1 year of age as the best form of infant nutrition. Breastfeeding for the first year of life provides optimal nutrition and benefits for the infant. Exclusive breastfeeding until 6 months of age is not in line with the AAP's recommendation for a full year. While commercially prepared infant formula is an alternative if breastfeeding is not possible, it is not the preferred choice according to AAP guidelines. The recommendation for commercial infant formula until 1 year of age is not in line with the AAP's stance on the benefits of extended breastfeeding.

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