Nursing Elites

1. What is the recommended position for a child with epiglottitis to ease breathing?

• A. Supine
• B. Prone
• C. Tripod
• D. Semi-Fowler’s

Correct answer: C

Rationale: The correct answer is C, 'Tripod.' In children with epiglottitis, the tripod position is recommended to help open the airway and ease breathing. This position involves the child sitting upright, leaning forward, and supporting themselves with their hands on their knees or another surface. This posture helps improve air entry into the lungs by maximizing the space for breathing. Choices A (Supine), B (Prone), and D (Semi-Fowler’s) are incorrect. Placing a child with epiglottitis in the supine position may further obstruct the airway, while the prone position and semi-Fowler’s position do not facilitate optimal air exchange in these cases.

2. After surgery yesterday for gastroesophageal reflux, the nurse finds that the infant has somehow removed the nasogastric (NG) tube. What nursing action is most appropriate to perform at this time?

• A. Notify the healthcare provider.
• B. Insert a new NG tube for feedings.
• C. Replace the NG tube to maintain gastric decompression.
• D. Leave the NG tube out as it may have been in long enough.

Correct answer: A

Rationale: The most appropriate action for the nurse to take in this situation is to notify the healthcare provider immediately. This is important as the removal of the NG tube can disrupt postoperative care, especially in terms of maintaining gastric decompression. Inserting a new NG tube without practitioner direction can be unsafe and is not within the nurse's scope of practice. Similarly, replacing the NG tube or leaving it out should be decided by the healthcare provider to ensure the infant's safety and appropriate postoperative care.

3. Which heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood?

• A. S1 and S2
• B. S3 and S4
• C. Murmur
• D. Physiologic splitting

Correct answer: C

Rationale: A murmur is produced by turbulent blood flow within the heart or major arteries, resulting in audible vibrations.

4. What term is appropriate terminology to use for an infant whose intrauterine growth rate was slowed and whose birth weight falls below the 10th percentile on intrauterine growth charts?

• A. Postterm
• B. Postmature
• C. Low birth weight
• D. Small for gestational age

Correct answer: D

Rationale: The correct answer is D, 'Small for gestational age.' A small for gestational age, or small-for-date, infant is any child whose intrauterine growth rate was slowed and whose birth weight falls below the 10th percentile on intrauterine growth curves. Choices A and B, 'Postterm' and 'Postmature,' refer to infants born after 42 weeks of gestational age regardless of birth weight, and do not specifically address growth rate. Choice C, 'Low birth weight,' refers to infants with a birth weight less than 2500 g (5.5 pounds) regardless of gestational age, which is a different classification compared to being small for gestational age.

5. The charge nurse in the pediatric unit is teaching nursing students about pyloric stenosis. A student asks what causes pyloric stenosis. How should the nurse respond?

• A. One portion of the intestines invaginates or telescopes into another
• B. Hypertrophy of the circular pylorus muscle
• C. Relaxed cardiac sphincter
• D. Absent ganglion cells in the colon

Correct answer: B

Rationale: Pyloric stenosis is caused by the hypertrophy (thickening) of the circular muscle of the pylorus, leading to obstruction. Choice A is incorrect as it describes intussusception, not pyloric stenosis. Choice C is incorrect as a relaxed cardiac sphincter is related to gastroesophageal reflux. Choice D is incorrect as it describes Hirschsprung's disease, not pyloric stenosis.

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