Nursing Elites

1. When should a mother introduce solid foods to her 4-month-old baby girl? The mother states, 'My mother says I should put rice cereal in the baby's bottle now.' The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?

• A. Stops rooting when hungry
• B. Opens mouth when food comes her way
• C. Awakens once for nighttime feedings
• D. Gives up a bottle for a cup

Correct answer: B

Rationale: The correct answer is B: 'Opens mouth when food comes her way.' This behavior indicates readiness to start trying solid foods. Infants should be introduced to solid foods based on developmental cues, such as showing an interest in food and the ability to accept it. Choices A, C, and D are not indicative of readiness for solid foods. Stopping rooting when hungry is a reflex that may persist beyond the readiness for solids. Awakening for nighttime feedings is a normal behavior for a 4-month-old, and transitioning from a bottle to a cup is a later developmental milestone.

2. A mother brings her 2-year-old son to the clinic because he has been crying and pulling on his earlobe for the past 12 hours. The child’s oral temperature is 101.2°F. Which intervention should the nurse implement?

• A. Ask the mother if the child has had a runny nose
• B. Cleanse purulent exudate from the affected ear canal
• C. Apply a topical antibiotic to the periauricle area
• D. Provide parent education to prevent recurrence

Correct answer: A

Rationale: In a child with ear pain and fever, asking about a runny nose is important to assess if the ear pain is associated with a respiratory infection, such as otitis media. This information can guide further assessment and treatment decisions. Choice B is incorrect because cleansing purulent exudate should be done by a healthcare provider, not the nurse. Choice C is incorrect as topical antibiotics should only be applied under healthcare provider's orders. Choice D is not the priority at this moment, as the immediate concern is assessing the association between the ear pain and a possible respiratory infection.

3. The nurse is caring for a 2-year-old child who was admitted for dehydration due to gastroenteritis. The child is now receiving IV fluids and appears more alert. What is the best indicator that the child’s condition is improving?

• A. The child is more alert and playful
• B. The child’s urine output has increased
• C. The child’s vital signs are stable
• D. The child is tolerating small amounts of oral fluids

Correct answer: B

Rationale: Increased urine output is a reliable indicator that hydration status is improving. While alertness and playfulness are positive signs, increased urine output directly reflects improved hydration. Stable vital signs are important but may not directly indicate hydration status. Tolerating small amounts of oral fluids is a good sign but may not be as direct an indicator as increased urine output.

4. When reinforcing teaching with the parents of a 7-year-old child with attention-deficit/hyperactivity disorder (ADHD) about the child's medication, which statement by the parents indicates an understanding of the medication's side effects?

• A. We should monitor our child's growth and appetite regularly.
• B. The medication may cause drowsiness, so we will give it at bedtime.
• C. We need to give the medication with food to avoid stomach upset.
• D. The medication can cause increased urination, so fluid intake should be limited.

Correct answer: A

Rationale: The correct answer is A: 'We should monitor our child's growth and appetite regularly.' Correct monitoring of the child's growth and appetite is crucial when a child is on ADHD medications, especially stimulants, as these medications can have side effects related to growth and appetite. Monitoring these parameters regularly helps in assessing the medication's impact and making any necessary adjustments. Choices B, C, and D are incorrect: B talks about drowsiness, C mentions avoiding stomach upset, and D refers to increased urination and limiting fluid intake. While these are potential side effects of medications, they do not directly address the importance of monitoring growth and appetite, which is crucial in children on ADHD medications.

5. The practical nurse is caring for a child who was admitted for treatment of seizures. Which intervention should the nurse implement to help prevent injury from a seizure?

• A. Have a padded tongue depressor at the bedside.
• B. Keep the side rails padded and in an upright position.
• C. Place a padded helmet on the child’s head.
• D. Restrain the child during the seizure activity.

Correct answer: B

Rationale: The correct intervention to help prevent injury during a seizure is to keep the side rails padded and in an upright position. This measure helps to ensure the child's safety by preventing falls or accidental injuries. Using a padded tongue depressor or restraining the child can potentially cause harm and are not recommended. Placing a padded helmet is not a standard intervention for seizure safety in this scenario.

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