Nursing Elites

1. When using the Ballard gestational assessment tool on a newborn, which of the following tests should be performed after the first hour of birth, allowing the newborn to recover from the stress of birth?

• A. Arm recoil
• B. Square window sign
• C. Scarf sign
• D. Popliteal angle

Correct answer: A

Rationale: The correct answer is Arm recoil. Arm recoil is slower in healthy but fatigued newborns after birth, making it best elicited after the first hour of birth when the baby has had time to recover from the stress of birth. This assessment helps evaluate neuromuscular maturity in newborns and is more accurate when performed after the initial recovery period. The other choices, Square window sign, Scarf sign, and Popliteal angle, are not specifically assessed using the Ballard gestational assessment tool and do not relate to the recovery period after birth.

2. 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.

3. What is the proper depth of chest compressions for a 9-month-old infant?

• A. 1/3 the diameter of the chest or about 1 1/2 inches.
• B. 1/4 the diameter of the chest or about 1 inch.
• C. 1/2 the diameter of the chest or about 2 inches.
• D. 1/3 the diameter of the chest or about 3/4 inch.

Correct answer: A

Rationale: When performing chest compressions on a 9-month-old infant, the proper depth is 1/3 the diameter of the chest, which equates to approximately 1 1/2 inches. This depth is crucial for effective cardiopulmonary resuscitation (CPR) in infants. Choice B, which suggests 1/4 the diameter of the chest or about 1 inch, is incorrect as it does not provide the recommended depth for infants. Choice C, stating 1/2 the diameter of the chest or about 2 inches, is too deep and may cause harm to the infant. Choice D, mentioning 1/3 the diameter of the chest or about 3/4 inch, is also incorrect as it underestimates the required depth for effective chest compressions on a 9-month-old infant.

4. In growing children, growth hormone deficiency results in short stature and very slow growth rates. Short stature may result from which of the following?

• A. Anterior pituitary gland hypofunction
• B. Posterior pituitary gland hyperfunction
• C. Parathyroid gland hyperfunction
• D. Thyroid gland hyperfunction

Correct answer: A

Rationale: Short stature in growing children can result from anterior pituitary gland hypofunction, which leads to growth hormone deficiency. The anterior pituitary gland plays a crucial role in stimulating the release of growth hormone, and when it is underactive (hypofunction), insufficient growth hormone is produced, resulting in short stature and slow growth rates.

5. What advice should a school-age child with type 1 diabetes mellitus follow to prevent hypoglycemia during soccer practice?

• A. Drink a cup of orange juice before soccer practice
• B. Eat twice the amount normally eaten at lunchtime
• C. Take half the amount of prescribed insulin on practice days
• D. Take the prescribed insulin at noontime rather than in the morning

Correct answer: A

Rationale: Drinking orange juice before soccer practice is recommended to prevent hypoglycemia in children with type 1 diabetes. Orange juice contains fast-acting carbohydrates that can quickly raise blood sugar levels if they drop during physical activity. Eating twice the amount normally eaten at lunchtime can lead to hyperglycemia, which is high blood sugar, rather than preventing hypoglycemia. Adjusting insulin doses should only be done under the guidance of a healthcare provider. Taking insulin at noontime rather than in the morning does not directly address preventing hypoglycemia during afternoon soccer practice.

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