Nursing Elites

1. Kimberly is having a checkup before starting kindergarten. The nurse asks her to do the “finger-to-nose test.” What is the purpose of this test?

• A. Deep tendon reflexes
• B. Cerebellar function
• C. Sensory discrimination
• D. Ability to follow directions

Correct answer: B

Rationale: The finger-to-nose test assesses cerebellar function, which is responsible for balance and coordination. The test evaluates how well the cerebellum controls motor functions and coordination. Choice A, deep tendon reflexes, is incorrect because this test does not assess reflexes but rather cerebellar function. Choice C, sensory discrimination, is incorrect as this test focuses on motor function rather than sensory abilities. Choice D, ability to follow directions, is incorrect since the test primarily assesses motor coordination and not cognitive skills related to following instructions.

2. A health care provider prescribes feedings of 1 to 2 oz Pedialyte every 3 hours and to advance to 1/2 strength Similac with iron as tolerated postoperatively for an infant who had a pyloromyotomy. The nurse should decide to advance the feeding if which occurs?

• A. The infant's IV line has infiltrated.
• B. The infant has not voided since surgery.
• C. The infant's mother states the infant is tolerating the feeding okay.
• D. The infant is taking the Pedialyte without vomiting or distention.

Correct answer: D

Rationale: The decision to advance feedings after a pyloromyotomy is based on the infant's ability to tolerate the current feedings without vomiting or abdominal distention. Ensuring the infant can keep down Pedialyte is the key indicator for moving to the next stage of feeding. Choices A, B, and C are incorrect because they do not directly relate to the infant's ability to tolerate the feeding. An infiltrated IV line, lack of voiding, or the mother's statement do not provide direct information on the infant's tolerance to the feeding, unlike the absence of vomiting and distention.

3. Several types of seizures can occur in neonates. What is characteristic of clonic seizures?

• A. Apnea
• B. Tremors
• C. Extension of all four limbs
• D. Jerking that cannot be stopped by flexion of the affected limb

Correct answer: D

Rationale: Clonic seizures are characterized by slow, rhythmic, jerking movements that cannot be stopped by flexion of the affected limb. Therefore, the correct characteristic of clonic seizures is option D. Option A, apnea, is not characteristic of clonic seizures. Option B, tremors, does not describe clonic seizures accurately. Option C, extension of all four limbs, is not a typical feature of clonic seizures but rather seen in tonic seizures.

4. An infant is born with a gastroschisis. Care preoperatively should include which priority intervention?

• A. Prone position
• B. Sterile water feedings
• C. Monitoring serum laboratory electrolytes
• D. Covering the defect with a sterile bowel bag

Correct answer: D

Rationale: The correct priority intervention for an infant with gastroschisis is to cover the exposed abdominal contents with a sterile bowel bag. This action helps protect the intestines from injury, contamination, and dehydration before surgical repair. Choice A, placing the infant in the prone position, is not appropriate as it does not address the immediate need to protect the exposed intestines. Choice B, sterile water feedings, and Choice C, monitoring serum laboratory electrolytes, are not the priority interventions for this condition. Sterile water feedings may not provide the necessary protection for the exposed intestines, and monitoring electrolytes, while important, is secondary to the immediate need for protection and hydration of the exposed abdominal contents.

5. A 10-month-old infant is diagnosed with gastroesophageal reflux. An esophageal (pH) probe monitor is ordered. What explanation for the purpose of the esophageal probe should the nurse provide to the parents?

• A. Assist in the passage of formula through the esophagus
• B. Identify the number of reflux episodes that are occurring
• C. Determine the time it takes for the stomach to empty its contents
• D. Monitor the pH within the stomach

Correct answer: B

Rationale: The correct answer is B. The esophageal pH probe is used to identify the frequency and severity of reflux episodes by measuring the pH in the esophagus. Choice A is incorrect because the probe does not assist in the passage of formula through the esophagus. Choice C is incorrect as determining the time it takes for the stomach to empty its contents would require a different procedure. Choice D is incorrect as the esophageal pH probe monitors the pH in the esophagus, not the stomach.

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