Nursing Elites

1. What procedure is most appropriate for the assessment of an abdominal circumference related to a bowel obstruction?

• A. Measuring the abdomen after feedings
• B. Marking the point of measurement with a pen
• C. Measuring the circumference at the symphysis pubis
• D. Using a new tape measure with each assessment to ensure accuracy

Correct answer: B

Rationale: Marking the point of measurement ensures consistent and accurate assessments of abdominal circumference, especially important in conditions like bowel obstruction where changes need to be monitored closely.

2. Which reflex, present at birth, is elicited by stroking the sole of the infant's foot, resulting in the fanning of the toes?

• A. Babinski
• B. Moro
• C. Sucking
• D. Rooting

Correct answer: A

Rationale: The Babinski reflex is the correct answer. This reflex is characterized by the fanning out of the toes when the sole of the foot is stroked. It is a normal reflex in infants and is typically present at birth, disappearing by around 12 months of age. The Moro reflex, which involves the infant's response to a sudden loss of support or a loud noise, is not related to the fanning of toes. Sucking and rooting reflexes are related to feeding behaviors and are not elicited by stroking the sole of the foot.

3. The nurse is caring for a child with a urinary tract infection who is on intravenous gentamicin (Garamycin). What interventions should the nurse plan for this child with regard to this medication? (Select all that apply.)

• A. Encourage fluids.
• B. Monitor urinary output.
• C. Monitor sodium serum levels.
• D. All above

Correct answer: D

Rationale: Gentamicin is an aminoglycoside antibiotic that requires monitoring of serum peak and trough levels to avoid toxicity, particularly nephrotoxicity and ototoxicity. Encouraging fluids and monitoring urinary output are also crucial to minimize the risk of kidney damage.

4. During a routine health assessment, the nurse notes that an 8-month-old infant has a significant head lag. Which is the most appropriate action?

• A. Recheck head control at the next visit
• B. Teach the parents appropriate exercises
• C. Schedule the child for further evaluation
• D. Refer the child for further evaluation if the anterior fontanel is still open

Correct answer: C

Rationale: Significant head lag at 8 months is concerning and warrants further evaluation, as it may indicate developmental delays or neurological issues.

5. The clinic nurse is instructing parents about caring for a toddler with ascariasis (common roundworm). Which statement made by the parents indicates a need for further teaching?

• A. We will wash our hands often, especially after diaper changes
• B. We know that roundworm can be transmitted from person to person
• C. We will be sure to continue the nitazoxanide (Alinia) orally for 3 days
• D. We will bring a stool sample to the clinic for examination in 2 weeks

Correct answer: B

Rationale: Roundworm (ascariasis) is typically transmitted through ingestion of contaminated soil, not directly from person to person. This statement indicates a misunderstanding requiring clarification.

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