Nursing Elites

1. Which reflex is expected to disappear by 4 months of age?

• A. Rooting reflex
• B. Moro reflex
• C. Babinski reflex
• D. Palmar grasp

Correct answer: B

Rationale: The Moro reflex, also known as the startle reflex, typically disappears by 4 months as the infant's nervous system matures. This reflex is important for assessing the development of the nervous system in newborns. The Rooting reflex (Choice A) is related to turning the head in response to cheek stimulation; the Babinski reflex (Choice C) involves the fanning of toes in response to foot stimulation; and the Palmar grasp (Choice D) is the curling of the fingers around an object placed in the infant's hand. These reflexes have different timelines for disappearance and are not typically expected to be gone by 4 months of age.

2. What is the most consistent and commonly used indicator of pain in infants?

• A. Increased respirations
• B. Increased heart rate
• C. Thrashing of arms and legs
• D. Facial expression of discomfort

Correct answer: D

Rationale: Facial expression has consistently been validated as an indicator of pain in infants. Behavioral pain measures are most reliable for sharp procedural pain in infants. Increased heart rate and respirations are indicative of a generalized and complex response to stress, not specific for pain in infants. Thrashing of arms and legs is a reliable indicator in young children, not specifically in infants.

3. The nurse is caring for a child with Beta Thalassemia. Which child is in a group most at risk for Beta Thalassemia?

• A. A three-year-old girl of Mediterranean descent.
• B. A ten-year-old boy of Hispanic descent.
• C. A young girl of African descent.
• D. A baby of European descent.

Correct answer: A

Rationale: Corrected Rationale: Beta Thalassemia is most common in individuals of Mediterranean descent, such as those from Italy, Greece, and the Middle East. This genetic disorder affects hemoglobin production and can lead to severe anemia. Choice A is the correct answer as individuals of Mediterranean descent are at the highest risk for Beta Thalassemia. Choices B, C, and D are incorrect as they do not belong to the population group most at risk for this genetic disorder.

4. What is a clinical manifestation of acetaminophen poisoning?

• A. Hyperpyrexia
• B. Hepatic involvement
• C. Severe burning pain in stomach
• D. Drooling and inability to clear secretions

Correct answer: B

Rationale: Acetaminophen poisoning primarily affects the liver, leading to hepatic involvement, which may present as jaundice, liver failure, or elevated liver enzymes. Hyperpyrexia, severe pain, and drooling are more associated with other types of poisoning.

5. 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.

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