Nursing Elites

1. Which of the following statements regarding the length-based resuscitation tape measure is correct?

• A. The resuscitation tape estimates a child's weight based on his or her height.
• B. It is a reliable tool in children who are less than 5 years of age.
• C. The red end of the tape measure is placed at the top of the child's head.
• D. The tape measure can be used in children who weigh up to 75 pounds.

Correct answer: D

Rationale: The length-based resuscitation tape measure is designed to estimate a child's weight based on their length and can be used for children weighing up to 75 pounds. It is a reliable tool for pediatric weight estimation in emergency situations.

2. Why should small children ride in the backseat of a vehicle?

• A. They are much less likely to be ejected from the vehicle.
• B. The back of the front seat will provide a cushion during a crash.
• C. They can experience severe injury or death if the airbag deploys.
• D. Their legs are highly prone to injury from striking the dashboard.

Correct answer: C

Rationale: Small children should ride in the backseat of a vehicle primarily to avoid severe injury or death that may occur if the airbag deploys. In the event of a crash, the force of an airbag deployment can be dangerous for a child seated in the front seat. Placing them in the backseat reduces the risk of serious harm from airbag impact and is a safer seating position for young passengers.

3. What comment made by a parent of a 1-month-old would alert the nurse about the presence of a congenital heart defect?

• A. He is always hungry.
• B. He tires out during feedings.
• C. He is fussy for several hours every day.
• D. He sleeps all the time.

Correct answer: B

Rationale: Observing a 1-month-old tiring out during feedings should alert the nurse to the possibility of a congenital heart defect. This symptom may indicate that the infant is expending excess energy to compensate for a heart issue, leading to fatigue during feeding. Choices A, C, and D do not directly relate to a congenital heart defect. Being always hungry, fussy, or sleeping a lot are not specific signs of a congenital heart defect in a 1-month-old.

4. When educating the mother of a child with respiratory disease who needs a lot of fluids, the mother tells the nurse that when she offers her 24-month-old son juice, he always shakes his head and says, 'No'. The nurse suggests that the mother:

• A. Be firm and hand him the glass
• B. Distract him with some food
• C. Let him see that he is making her angry
• D. Offer him a choice of two things to drink

Correct answer: D

Rationale: Offering a choice can help the child feel more in control and willing to drink. By providing the child with options, the mother empowers him to make a decision, which can increase his willingness to drink fluids. This approach promotes a sense of autonomy and may lead to a more positive response from the child, ultimately contributing to better fluid intake, especially important for a child with a respiratory disease.

5. Which of the following findings is abnormal?

• A. Rapid, irregular breathing in a newly born infant
• B. Heart rate of 80 beats/min in a 3-month-old infant
• C. Respiratory rate of 26 breaths/min in a 2-year-old child
• D. Systolic BP of 100 mm Hg in a 10-year-old child

Correct answer: B

Rationale: A heart rate of 80 beats per minute in a 3-month-old infant is abnormally low for that age group and could indicate underlying health issues. The normal heart rate for a 3-month-old infant is typically higher, around 100-150 beats per minute. Therefore, this finding stands out as abnormal and warrants further evaluation. Choice A is not necessarily abnormal in a newly born infant as irregular breathing patterns can be common during the neonatal period. Choice C falls within the normal respiratory rate range for a 2-year-old child, which is around 20-30 breaths per minute. Choice D reflects a systolic blood pressure value within the normal range for a 10-year-old child, which is typically around 90-110 mm Hg.

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