Nursing Elites

1. The nurse is admitting a child with severe isotonic dehydration. Which intravenous fluid should the nurse anticipate the doctor to order initially to replace fluids?

• A. 0.9% normal saline
• B. D5 0.2% (1/4) normal saline
• C. D5W
• D. Albumin

Correct answer: A

Rationale: In the case of severe isotonic dehydration, the initial fluid of choice is 0.9% normal saline. This solution is preferred because it helps to restore both fluids and electrolytes effectively. Options B, C, and D are not suitable for the initial management of severe isotonic dehydration. D5 0.2% (1/4) normal saline (Choice B) is a hypotonic solution and might worsen the imbalance. D5W (Choice C) is a hypotonic solution that does not contain electrolytes essential for rehydration. Albumin (Choice D) is a colloid solution used for specific indications like hypoproteinemia or hypoalbuminemia, not for initial rehydration in severe dehydration.

2. Which reflex, present at birth, is elicited by stroking the sole of the infant's foot, resulting in the fanning of the toes?

• A. Babinski
• B. Moro
• C. Sucking
• D. Rooting

Correct answer: A

Rationale: The Babinski reflex is the correct answer. This reflex is characterized by the fanning out of the toes when the sole of the foot is stroked. It is a normal reflex in infants and is typically present at birth, disappearing by around 12 months of age. The Moro reflex, which involves the infant's response to a sudden loss of support or a loud noise, is not related to the fanning of toes. Sucking and rooting reflexes are related to feeding behaviors and are not elicited by stroking the sole of the foot.

3. What is often the initial sign of acute rheumatic fever in children?

• A. Polyarthritis
• B. Carditis
• C. Erythema marginatum
• D. Sydenham chorea

Correct answer: A

Rationale: Polyarthritis is indeed frequently the initial sign of acute rheumatic fever in children. It presents as joint pain, swelling, and redness. Carditis (inflammation of the heart), Erythema marginatum (a skin rash), and Sydenham chorea (involuntary muscle movements) are typically seen in the later stages of acute rheumatic fever and not as the initial sign.

4. The nurse is assessing a 3-year-old African American child whose height and weight are at the 20th percentile on the growth chart. What should the nurse recognize?

• A. The data suggest the child requires nutritional intervention
• B. The NCHS charts are accurate for U.S. African American children
• C. A correction factor is used for nonwhite ethnic groups
• D. No assessment can be made until several measurements are plotted over time

Correct answer: B

Rationale: The NCHS growth charts serve as reference guides for all racial or ethnic groups, including African American children. The 20th percentile for height and weight does not indicate nutritional failure but provides a reference point for ongoing assessment. Choice A is incorrect because being at the 20th percentile does not automatically imply the need for nutritional intervention. Choice C is incorrect as there is no correction factor specifically used for nonwhite ethnic groups in this context. Choice D is incorrect as a single measurement at the 20th percentile can provide valuable information for assessment.

5. What is characteristic of a neonate’s vision?

• A. Pupils react to light
• B. Tear glands function
• C. Blink reflex is absent
• D. Ciliary muscles are mature

Correct answer: A

Rationale: The correct answer is A: 'Pupils react to light.' Newborns' pupils do react to light, indicating that the visual pathway is functioning. However, a neonate's vision is still developing, and they can only focus on objects close to their face. Choice B is incorrect because tear glands are functional at birth. Choice C is incorrect because the blink reflex is present in neonates and helps protect their eyes. Choice D is incorrect as neonates' ciliary muscles are not fully developed.

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