Nursing Elites

1. Which assessment finding for a 4-month-old infant would require further action by the nurse?

• A. The posterior fontanel is open.
• B. The infant has good head control when held upright.
• C. The infant is able to roll only from abdomen to back.
• D. The anterior fontanel is open and soft.

Correct answer: A

Rationale: The correct answer is A. The posterior fontanel should be closed by 4 months of age. An open posterior fontanel at this age may indicate a delay in normal closure, which could be a cause for concern and require further evaluation by the healthcare provider to ensure proper development and growth. Choices B, C, and D are typical developmental milestones for a 4-month-old infant and do not raise immediate concerns requiring further action by the nurse.

2. A parent of a preschooler is being taught by a nurse about administering ear drops. Which of the following statements by the parent indicates an understanding of the teaching?

• A. I will straighten my child's ear canal by pulling it upward and backward.
• B. I will administer the ear drops immediately after removing them from the refrigerator.
• C. I will pull the ear lobe down and back before administering the ear drops.
• D. I will massage my child's ear after administering the ear drops.

Correct answer: D

Rationale: Correct administration of ear drops includes massaging the child's ear after administering the drops to facilitate proper absorption of the medication. This action helps ensure the effectiveness of the treatment. Choices A, B, and C are incorrect. Choice A describes incorrect positioning of the ear canal, choice B mentions incorrect storage of the ear drops, and choice C describes an incorrect technique for administering ear drops.

3. A child receives a vaccine for MMR. Six hours after the injection, the child�s parent reports local soreness, erythema, lethargy, and a fever of 101�F to a nurse. Which action should the nurse take?

• A. Give instructions on relieving symptoms with acetaminophen
• B. Seek emergency help, because these symptoms are signs of anaphylactic reaction
• C. Tell the parent that a live vaccine will cause a mild case of measles
• D. Obtain and fill out a Vaccine Adverse Event Report form

Correct answer: A

Rationale: Low-grade fever, malaise, and muscle aches are common reactions. Acetaminophen usually alleviates these problems. MMR is a live vaccine but it is attenuated or completely avirulent and does not cause measles in healthy children, only immunocompromised children.

4. When discussing the correction of hypospadias in a newborn, what does the nurse explain about this condition?

• A. No intervention is required as the defect will correct itself over time.
• B. Surgical repair of hypospadias is typically performed before 18 months of age.
• C. Corrective surgery is commonly postponed until preschool age.
• D. Repairing the defect does not increase the risk of testicular cancer.

Correct answer: B

Rationale: Hypospadias is a congenital condition where the opening of the urethra is on the underside of the penis. Surgical repair is the primary treatment for hypospadias and is usually recommended to be done before 18 months of age. This timing is preferred for optimal cosmetic and functional outcomes. Waiting until preschool age for corrective surgery may increase the complexity of the procedure and potential complications. Correcting hypospadias does not impact the risk of testicular cancer.

5. When caring for an infant with respiratory syncytial virus (RSV), which of the following actions should the nurse take?

• A. Administer antibiotics IM once per day.
• B. Initiate droplet precautions.
• C. Place the infant in a negative-pressure isolation room.
• D. Suction the nasopharynx as needed.

Correct answer: D

Rationale: When caring for an infant with respiratory syncytial virus (RSV), maintaining a patent airway is crucial. Suctioning the nasopharynx as needed helps clear secretions, prevent airway obstruction, and promote effective breathing. This intervention can aid in improving the infant's respiratory status and overall comfort. Administering antibiotics IM once per day (Choice A) is not indicated for RSV as it is caused by a virus, not bacteria. Initiating droplet precautions (Choice B) is important to prevent the spread of respiratory infections like RSV, but directly caring for the infant involves more specific interventions. Placing the infant in a negative-pressure isolation room (Choice C) is generally reserved for airborne infections, not RSV which spreads through respiratory droplets.

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