Nursing Elites

1. 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.

2. Which laboratory test would be most important for the nurse to assess when caring for a toddler suspected of having cystic fibrosis?

• A. Liver enzymes
• B. Serum calcium
• C. Sweat chloride test
• D. Urine creatinine

Correct answer: C

Rationale: The sweat chloride test is the primary diagnostic test for cystic fibrosis. Cystic fibrosis is characterized by abnormal transport of chloride and sodium across epithelial cell membranes, leading to increased chloride in sweat. This test is crucial for diagnosing cystic fibrosis in suspected cases. Liver enzymes (Choice A), serum calcium (Choice B), and urine creatinine (Choice D) are not specific tests for cystic fibrosis and would not provide the necessary information for diagnosis in this case.

3. What tool would be most useful to assess maternal and newborn attachment behaviors?

• A. Apgar
• B. Ballard scale
• C. NCAST (Nursing Child Assessment Satellite Training) Feeding Scale
• D. Brazelton Neonatal Behavioral Assessment Scale

Correct answer: C

Rationale: The NCAST Feeding Scale is the most suitable tool to evaluate maternal and newborn attachment behaviors during feedings. It focuses on observing the interaction between the parent and infant, providing insights into their bonding. The Apgar score is used to assess a neonate's immediate transition to life outside the womb, not specifically maternal and newborn attachment behaviors. The Ballard scale is used to estimate gestational age, not to assess attachment behaviors. The Brazelton Neonatal Behavioral Assessment Scale is designed to evaluate a newborn's responses to various stimuli, not specifically maternal and newborn attachment behaviors.

4. A 12-month-old infant has been diagnosed with failure to thrive (FTT). Which assessment findings does the nurse expect to be documented with this infant?

• A. Fear of strangers
• B. Minimal smiling
• C. Avoidance of eye contact
• D. All of the above

Correct answer: D

Rationale: These behaviors are consistent with FTT and indicate social withdrawal, which is often observed in infants who are not thriving. A wide-eyed gaze and avoidance of eye contact can also indicate developmental delays or emotional disturbances.

5. Which inpatient pediatric patient would not be able to go to the playroom due to their physical condition?

• A. A 4-year-old with chickenpox
• B. A 12-year-old with a fractured femur
• C. A 7-year-old with new-onset diabetes mellitus
• D. A 10-year-old postoperative appendectomy

Correct answer: A

Rationale: The correct answer is A. A child with chickenpox should not go to the playroom due to being contagious, as the virus can easily spread to other children. Children with fractures (choice B), new-onset diabetes mellitus (choice C), or postoperative appendectomy (choice D) do not pose a risk of spreading an infectious disease, so they can safely go to the playroom.

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