Nursing Elites

1. In contrast to the contractions associated with true labor, Braxton-Hicks contractions:

• A. generally follow rupture of the amniotic sac and occur with regularity.
• B. may be intensified by activity and are accompanied by a pink discharge.
• C. do not increase in intensity and are alleviated by a change in position.
• D. consistently become stronger and are not alleviated by changing position.

Correct answer: C

Rationale: Braxton-Hicks contractions are irregular and usually do not increase in intensity. Unlike true labor contractions, they tend to alleviate with a change in position, making option C the correct choice. Choices A, B, and D are incorrect because Braxton-Hicks contractions do not follow rupture of the amniotic sac, are not intensified by activity or accompanied by a pink discharge, and do not consistently become stronger or are not alleviated by changing position.

2. In educating the parents of a child diagnosed with hypothyroidism, the nurse mentions that the child should avoid goitrogens. Which of the following will the nurse mention as an example?

• A. Orange
• B. Tomatoes
• C. Cabbage
• D. Grapes

Correct answer: C

Rationale: Cabbage is an example of a goitrogen that should be avoided in children with hypothyroidism. Goitrogens are substances that can interfere with thyroid function by inhibiting iodine uptake, potentially worsening the condition. Cabbage, along with other cruciferous vegetables like broccoli and cauliflower, contains compounds that can affect thyroid hormone production. Oranges, tomatoes, and grapes are not classified as goitrogens. Therefore, it is important for parents to be aware of foods like cabbage and to limit their child's intake to help manage their hypothyroidism effectively.

3. 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.

4. Why should small children ride in the backseat of a vehicle?

• A. They are much less likely to be ejected from the vehicle.
• B. The back of the front seat will provide a cushion during a crash.
• C. They can experience severe injury or death if the airbag deploys.
• D. Their legs are highly prone to injury from striking the dashboard.

Correct answer: C

Rationale: Small children should ride in the backseat of a vehicle primarily to avoid severe injury or death that may occur if the airbag deploys. In the event of a crash, the force of an airbag deployment can be dangerous for a child seated in the front seat. Placing them in the backseat reduces the risk of serious harm from airbag impact and is a safer seating position for young passengers.

5. During the initial assessment of the newborn, which of the following data would be considered normal?

• A. Chest circumference 31.5 cm, head circumference 33.5 cm
• B. Chest circumference 30 cm, head circumference 29 cm
• C. Chest circumference 38 cm, head circumference 31.5 cm
• D. Chest circumference 32.5 cm, head circumference 36 cm

Correct answer: A

Rationale: The correct answer is A. During the initial assessment of a newborn, the average head circumference at birth is 32 to 37 cm, while the average chest circumference ranges from 30 to 35 cm. Normally, the head's circumference is about 2 cm greater than the chest circumference at birth. Choice A provides measurements of chest circumference 31.5 cm and head circumference 33.5 cm, both falling within the normal range in terms of actual size and relative size. Choices B, C, and D do not align with the typical measurements seen in a healthy newborn. Choice B has both circumferences below the average range, choice C has the chest circumference above the average, and choice D has the head circumference notably higher than the chest circumference, which is not typical for a newborn.

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