Nursing Elites

1. Parents would suspect hearing loss if their child did not:

• A. Turn away from a sound
• B. Startle with sudden loud noises immediately after birth
• C. Talk at 4 months
• D. Babble at 2 months

Correct answer: D

Rationale: The correct answer is D because babbling is an early indicator of hearing ability in infants. Lack of babbling by 2 months may suggest a potential hearing issue. Choices A, B, and C are incorrect because turning away from a sound, startling with sudden loud noises immediately after birth, and talking at 4 months are not primary indicators of hearing loss in infants.

2. The nurse is preparing to assess a 10-month-old infant. He is sitting on his father's lap and appears to be afraid of the nurse and of what might happen next. Which initial actions by the nurse should be most appropriate?

• A. Initiate a game of peek-a-boo.
• B. Ask the infant's father to place the infant on the examination table
• C. Talk softly to the infant while taking him from his father
• D. Undress the infant while he is still sitting on his father’s lap

Correct answer: A

Rationale: Engaging the infant in a familiar game like peek-a-boo can help reduce fear and build rapport before starting the assessment.

3. What is the primary objective of care for the child with minimal change nephrotic syndrome (MCNS)?

• A. Reduce blood pressure
• B. Lower serum protein levels
• C. Minimize excretion of urinary protein
• D. Increase the ability of tissue to retain fluid

Correct answer: C

Rationale: The primary objective in managing MCNS is to minimize the excretion of urinary protein, which is responsible for the hypoalbuminemia and subsequent edema in these patients.

4. When assessing an infant with intussusception, what type of stool would the nurse expect to find?

• A. Soft, seedy stool
• B. Currant-jelly stool
• C. Ribbon-like stool
• D. Soft and pasty stool

Correct answer: B

Rationale: The correct answer is B: Currant-jelly stool. This type of stool, which is red and mucous-like, is a classic sign of intussusception in infants. Choice A (Soft, seedy stool) is incorrect as it does not specifically describe the characteristic stool associated with intussusception. Choice C (Ribbon-like stool) is incorrect; ribbon-like stool may be seen in conditions like colon cancer, not intussusception. Choice D (Soft and pasty stool) is also incorrect as it does not match the typical stool finding in intussusception.

5. The apnea monitor alarm sounds on a neonate for the third time during this shift. What is the priority action by the nurse?

• A. Provide tactile stimulation.
• B. Administer 100% oxygen.
• C. Investigate possible causes of a false alarm.
• D. Assess infant for color and presence of respirations.

Correct answer: D

Rationale: The priority action for the nurse when the apnea monitor alarm sounds on a neonate is to assess the infant for color and the presence of respirations. This initial assessment helps determine the infant's respiratory status and the need for immediate intervention. Providing tactile stimulation or administering oxygen should only be done after assessing the infant's respiratory status. Investigating possible causes of a false alarm comes after ensuring the infant's well-being through the initial assessment.

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