Nursing Elites

1. When is a newborn considered premature?

• A. Weighs less than 6.5 pounds.
• B. Is born to a heroin-addicted mother.
• C. Is born before 37 weeks gestation.
• D. Has meconium in or around its mouth.

Correct answer: C

Rationale: A newborn is considered premature if it is born before 37 weeks gestation. Premature birth increases the risk of various health problems as the baby may not be fully developed. Choice A is incorrect because the weight alone does not determine prematurity. Choice B is incorrect as it refers to a specific situation but not a direct indicator of prematurity. Choice D is incorrect as the presence of meconium does not solely indicate prematurity.

2. Seizures in children MOST often result from:

• A. a life-threatening infection.
• B. an inflammatory process in the brain.
• C. an abrupt rise in body temperature.
• D. a temperature greater than 102°F.

Correct answer: C

Rationale: Seizures in children most often result from febrile seizures, which are triggered by an abrupt rise in body temperature. Febrile seizures are common in young children, especially between the ages of 6 months to 5 years, and are usually associated with viral infections that cause a sudden spike in body temperature. Choices A, B, and D are incorrect because while infections, inflammatory processes, and high temperatures can sometimes lead to seizures, the most common cause of seizures in children is an abrupt increase in body temperature, known as febrile seizures.

3. What is the most likely cause of a sudden onset of respiratory distress in a 5-year-old child with no fever?

• A. Infection of the lower airways.
• B. A progressive upper airway infection.
• C. Inflammation of the upper airway.
• D. A foreign body airway obstruction.

Correct answer: D

Rationale: A sudden onset of respiratory distress in a child without fever is most likely due to a foreign body airway obstruction. This obstruction can rapidly lead to difficulty breathing, stridor, and other signs of respiratory distress without necessarily causing a fever. Prompt recognition and intervention are crucial in such cases to prevent further complications and ensure the child's airway remains clear.

4. The client is being taught about perineal care postpartum. Which instruction should the client receive?

• A. Use ice packs to reduce swelling for the first 24 hours.
• B. Apply heat packs immediately after birth to reduce pain.
• C. Avoid using a peri-bottle to cleanse the perineum.
• D. Use tampons to absorb lochia discharge.

Correct answer: A

Rationale: The correct instruction for the client postpartum is to use ice packs to reduce swelling for the first 24 hours. This helps alleviate discomfort and promote healing. Applying heat packs immediately after birth is not recommended as they can increase swelling. A peri-bottle is advised for cleansing the perineum, not to be avoided. Tampons should not be used to absorb lochia discharge as they can increase the risk of infection. Therefore, the use of ice packs is the most appropriate and beneficial instruction for perineal care postpartum.

5. An 18-month-old child presents with fever, nasal flaring, intercostal retractions, and a respiratory rate of 50 bpm. What is the most appropriate nursing diagnosis?

• A. High risk for altered body temperature (hyperthermia)
• B. Ineffective breathing pattern
• C. Ineffective individual coping
• D. Knowledge deficit

Correct answer: B

Rationale: The most appropriate nursing diagnosis for the 18-month-old child presenting with fever, nasal flaring, intercostal retractions, and a respiratory rate of 50 bpm is 'Ineffective breathing pattern.' These symptoms collectively indicate respiratory distress, which aligns with the nursing diagnosis of ineffective breathing pattern. Nasal flaring, intercostal retractions, and an increased respiratory rate are signs of respiratory distress in pediatric patients, suggesting the need for immediate intervention to address the underlying breathing difficulties.

Similar Questions