Nursing Elites

1. A child is being assessed for suspected intussusception. What clinical manifestation is the nurse likely to observe?

• A. Projectile vomiting
• B. Currant jelly stools
• C. Abdominal distension
• D. Constipation

Correct answer: C

Rationale: The correct clinical manifestation that a nurse is likely to observe in a child with suspected intussusception is abdominal distension. Intussusception is a medical emergency where a part of the intestine folds into itself, causing obstruction. Abdominal distension is a common symptom due to the obstruction and the build-up of gases and fluids. While currant jelly stools (Choice B) are a classic sign of intussusception, they are typically seen in later stages of the condition and may not be present during the initial assessment. Projectile vomiting (Choice A) is more commonly associated with conditions like pyloric stenosis. Constipation (Choice D) is not a typical manifestation of intussusception; the condition usually presents with severe colicky abdominal pain and possible passage of blood and mucus in stools.

2. A child has undergone surgery using steel bar placement to correct pectus excavatum. What position would the nurse instruct the parents to avoid?

• A. Semi-Fowler
• B. Supine
• C. High Fowler
• D. Side-lying

Correct answer: D

Rationale: The correct answer is D: Side-lying. After surgery using steel bar placement to correct pectus excavatum, the nurse should instruct the parents to avoid placing the child in a side-lying position. This position should be avoided to prevent displacement of the steel bar. Choices A, B, and C are incorrect. Semi-Fowler, Supine, and High Fowler positions are generally safe and commonly used in postoperative care, but in this specific case, side-lying should be avoided to ensure the effectiveness of the surgical correction.

3. A 3-month-old infant has been hospitalized with respiratory syncytial virus (RSV). What is the priority intervention?

• A. Administering an antiviral agent
• B. Clustering care to conserve energy
• C. Offering oral fluids to promote hydration
• D. Providing an antitussive agent when necessary

Correct answer: B

Rationale: The priority intervention for a 3-month-old infant hospitalized with respiratory syncytial virus (RSV) is to cluster care to conserve energy. Infants with RSV often have difficulty breathing and need to rest frequently. Clustering care involves grouping nursing interventions to allow for longer periods of rest between activities, which helps prevent exhaustion and conserve the infant's energy. Administering an antiviral agent is not the primary intervention for RSV, as it is a viral infection and antiviral agents are not typically used for RSV. Offering oral fluids is important for hydration but may not be the priority when the infant is struggling to breathe. Providing an antitussive agent should be done judiciously and under medical guidance, as suppressing the cough reflex can be detrimental in RSV cases where coughing helps clear airway secretions.

4. While performing a visual inspection of a 30-year-old woman in active labor, you can see the umbilical cord at the vaginal opening. After providing high concentration oxygen, you should next

• A. massage the uterus to facilitate delivery of the fetus
• B. relieve pressure from the cord with your gloved fingers
• C. place the mother on her left side and provide rapid transport
• D. elevate the mother's lower extremities and provide immediate transport

Correct answer: B

Rationale: In the scenario described, when the umbilical cord is visible at the vaginal opening, the priority is to relieve pressure from the cord with gloved fingers. This action helps prevent cord compression and ensures continued oxygenation to the fetus, which is crucial for the baby's well-being. Massaging the uterus or elevating the mother's lower extremities is not the correct course of action in this situation and may potentially worsen the condition. Placing the mother on her left side and providing rapid transport is not the immediate step needed to address the visible umbilical cord; relieving pressure from the cord takes precedence to maintain fetal oxygen supply.

5. An infant with a congenital heart defect is being given gavage feedings. The parents ask the nurse why this is necessary. How should the nurse respond?

• A. It limits the chance of vomiting.
• B. It allows the feeding to be administered rapidly.
• C. The energy that would have been expended on sucking is conserved.
• D. The quantity of nutritional liquid can be regulated better than with a bottle.

Correct answer: C

Rationale: Gavage feedings are necessary for infants with congenital heart defects to conserve the infant's energy by eliminating the need for sucking. This is important because sucking requires energy expenditure, which can be taxing for infants with cardiac defects. Choice A is incorrect as gavage feedings do not primarily limit the chance of vomiting. Choice B is incorrect because the speed of feeding administration is not the primary reason for using gavage feedings in this case. Choice D is incorrect as the regulation of the quantity of nutritional liquid is not the main purpose of gavage feedings in infants with congenital heart defects.

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