Nursing Elites

1. During a routine health assessment, the nurse notes that an 8-month-old infant has a significant head lag. Which is the most appropriate action?

• A. Recheck head control at the next visit
• B. Teach the parents appropriate exercises
• C. Schedule the child for further evaluation
• D. Refer the child for further evaluation if the anterior fontanel is still open

Correct answer: C

Rationale: Significant head lag at 8 months is concerning and warrants further evaluation, as it may indicate developmental delays or neurological issues.

2. A mother delivers an infant at 30 weeks gestation and asks if formula is better than breast milk since the baby is premature. What should the nurse respond?

• A. Human milk is preferred over other types of nutrition
• B. Human milk lacks essential nutrients for preterm infants
• C. Commercial infant formulas are preferred for preterm infants
• D. Commercial formulas have not been designed to meet preterm infants' needs

Correct answer: A

Rationale: Human milk is preferred, even for preterm infants, because it contains essential nutrients and antibodies that are particularly beneficial for their growth and development. Choice B is incorrect because human milk is rich in essential nutrients necessary for preterm infants. Choice C is incorrect as commercial infant formulas do not provide the same benefits as human milk. Choice D is incorrect as specialized formulas are available to meet the unique nutritional needs of preterm infants, but human milk remains the optimal choice.

3. The nurse is caring for a child with acute renal failure. What laboratory findings should the nurse expect to find? (Select all that apply.)

• A. Hyponatremia
• B. Hyperkalemia
• C. All are applicable
• D. Elevated blood urea nitrogen level

Correct answer: C

Rationale: In acute renal failure, laboratory findings typically include hyperkalemia, hyponatremia, and elevated blood urea nitrogen (BUN) levels due to the kidneys' inability to excrete waste and balance electrolytes. Metabolic alkalosis is less common, with metabolic acidosis being more typical.

4. In children with Type 1 diabetes, what is a common early sign of hypoglycemia?

• A. Irritability
• B. Rapid heartbeat
• C. Confusion
• D. Sweating

Correct answer: D

Rationale: Sweating is indeed one of the earliest signs of hypoglycemia in children with Type 1 diabetes. When blood sugar levels drop too low, the body releases stress hormones like adrenaline, which can lead to sweating. While irritability, rapid heartbeat, and confusion can also be seen in hypoglycemia, sweating is particularly common as a quick indicator of low blood sugar levels in children with Type 1 diabetes.

5. What interventions should be implemented to maintain the skin integrity of a preterm infant born at 30 weeks?

• A. Avoid cleaning the skin
• B. Bathe the infant with sterile water
• C. Cleanse the skin with a gentle alkaline-based soap and water
• D. Thoroughly rinse the skin with plain water after bathing

Correct answer: B

Rationale: The correct intervention to maintain the skin integrity of a preterm infant born at 30 weeks is to bathe the infant with sterile water. Bathing with sterile water or a neutral pH solution is recommended to protect the delicate skin of preterm infants, which is more permeable and prone to damage. Choices A, C, and D are incorrect as avoiding cleaning the skin may lead to hygiene issues, cleansing with alkaline-based soap can be harsh on the delicate skin, and thoroughly rinsing with plain water after bathing may not be as gentle and protective for preterm infants.

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