Nursing Elites

1. Which of the following clinical signs would MOST suggest acute respiratory distress in a 2-month-old infant?

• A. Heart rate of 130 beats/min
• B. Respiratory rate of 30 breaths/min
• C. Abdominal breathing
• D. Grunting respirations

Correct answer: D

Rationale: Grunting respirations are a key clinical sign of acute respiratory distress in infants. Grunting is a protective mechanism where the infant exhales against a partially closed glottis to increase functional residual capacity and oxygenation. This is often seen in conditions such as respiratory distress syndrome, pneumonia, or other causes of respiratory compromise in infants. Monitoring respiratory patterns like grunting is crucial for early recognition and intervention in infants with respiratory distress. Choices A, B, and C are less specific to acute respiratory distress in infants. While an elevated heart rate and respiratory rate can be present in respiratory distress, grunting respirations are a more direct indicator of significant respiratory compromise in infants.

2. During the initial assessment of the newborn, which of the following data would be considered normal?

• A. Chest circumference 31.5 cm, head circumference 33.5 cm
• B. Chest circumference 30 cm, head circumference 29 cm
• C. Chest circumference 38 cm, head circumference 31.5 cm
• D. Chest circumference 32.5 cm, head circumference 36 cm

Correct answer: A

Rationale: The correct answer is A. During the initial assessment of a newborn, the average head circumference at birth is 32 to 37 cm, while the average chest circumference ranges from 30 to 35 cm. Normally, the head's circumference is about 2 cm greater than the chest circumference at birth. Choice A provides measurements of chest circumference 31.5 cm and head circumference 33.5 cm, both falling within the normal range in terms of actual size and relative size. Choices B, C, and D do not align with the typical measurements seen in a healthy newborn. Choice B has both circumferences below the average range, choice C has the chest circumference above the average, and choice D has the head circumference notably higher than the chest circumference, which is not typical for a newborn.

3. You are treating a 5-year-old child who has had severe diarrhea and vomiting for 3 days and is now showing signs of shock. Supplemental oxygen has been given, and you have elevated his lower extremities. En route to the hospital, you note that his work of breathing has increased. You should:

• A. begin positive-pressure ventilations and reassess the child.
• B. lower the extremities and reassess the child.
• C. listen to the lungs with a stethoscope for abnormal breath sounds.
• D. insert a nasopharyngeal airway and increase the oxygen flow.

Correct answer: B

Rationale: When the work of breathing increases after elevating the legs, it is important to lower the extremities. Elevating the lower extremities in a child with signs of shock can worsen the condition by reducing venous return to the heart. Lowering the extremities can help improve venous return and potentially alleviate the increased work of breathing.

4. Which of the following techniques represents the MOST appropriate method of opening the airway of an infant with no suspected neck injury?

• A. Perform the technique as you would for an older child or adult.
• B. Lift up the chin and hyperextend the neck.
• C. Gently lift the chin while maintaining slight flexion of the neck.
• D. Tilt the head back without hyperextending the neck.

Correct answer: D

Rationale: Tilting the head back without hyperextending the neck is the safest way to open an infant's airway. Hyperextending the neck can potentially cause harm to the infant, making option D the most appropriate method for opening an infant's airway without suspected neck injury.

5. How can a new mother tell if her baby is getting enough breast milk?

• A. If your baby sleeps through the night, they are getting enough milk.
• B. If your baby has six to eight wet diapers a day, they are getting enough milk.
• C. If your baby cries frequently, they are getting enough milk.
• D. If your baby is awake and alert, they are getting enough milk.

Correct answer: B

Rationale: The correct answer is B. If a new mother observes that her baby has six to eight wet diapers a day, it indicates that the baby is getting enough breast milk. This is a crucial indicator of adequate milk intake and hydration in infants. Conversely, choices A, C, and D are incorrect. A baby sleeping through the night, crying frequently, or being awake and alert are not reliable indicators of sufficient breast milk intake. It is essential for new mothers to track their baby's diaper output to ensure they are receiving the necessary nutrition.

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