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. When a father asks why his child with tetralogy of Fallot seems to favor a squatting position, the nurse would explain that squatting:

• A. Increases peripheral vascular resistance
• B. Decreases arterial blood flow away from the heart
• C. It's a common resting position when a child is tachycardic
• D. Increases the workload of the heart

Correct answer: A

Rationale: Squatting increases systemic vascular resistance, which leads to a reduction in the right-to-left shunting of blood in children with tetralogy of Fallot. This helps improve oxygenation by balancing the pulmonary and systemic blood flow. The squatting position decreases the pressure in the right ventricle and reduces the magnitude of the right-to-left shunt by increasing afterload, thereby improving oxygenation. Choices B, C, and D are incorrect because squatting does not decrease arterial blood flow away from the heart, is not related to being tachycardic, and does not increase the workload of the heart.

3. A 3-year-old child has been admitted to your pediatric ward. The doctor gave a provisional diagnosis of respiratory tract infection. After careful assessment and history, a final diagnosis of lower respiratory infection was made. Which of the following signs will confirm the diagnosis?

• A. Cough
• B. Fever
• C. Inability to lie supine
• D. Inability to eat

Correct answer: C

Rationale: Inability to lie supine is a characteristic sign of lower respiratory infection. This positioning preference is often seen in patients with lower respiratory infections due to discomfort or difficulty breathing when lying flat on their back. While cough and fever are common symptoms associated with respiratory infections, they are not specific to lower respiratory infections. Inability to eat may indicate general illness or discomfort but is not a specific indicator of lower respiratory infection.

4. When is it MOST appropriate to clamp and cut the umbilical cord?

• A. Before the newborn has taken its first breath
• B. After the placenta has completely delivered
• C. As soon as the cord has stopped pulsating
• D. Immediately following delivery of the newborn

Correct answer: C

Rationale: The ideal time to clamp and cut the umbilical cord is when it has stopped pulsating. This allows for the transfer of remaining blood from the placenta to the newborn, which can be beneficial for the baby's health and iron stores. Clamping the cord too early can deprive the newborn of this essential blood volume. Waiting for the pulsations to cease ensures that the baby receives the maximum benefits from delayed cord clamping.

5. When responding to a call for a 2-year-old child who fell from a second-story window, with the mechanism of injury and the age of the patient in mind, you should suspect that the primary injury occurred to the child's:

• A. chest.
• B. head.
• C. lower extremities.
• D. abdomen.

Correct answer: B

Rationale: In a scenario where a young child falls from a significant height like a second-story window, the primary injury is more likely to be to the head. This is because young children have proportionately larger head sizes compared to their body, making them more susceptible to head injuries in such falls. The chest (Choice A), lower extremities (Choice C), and abdomen (Choice D) are less likely to sustain the primary injury in this scenario, as the impact of the fall and the child's anatomy predispose the head to be the most affected area.

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