Nursing Elites

1. The nurse is assessing a postpartum client's fundus. Where should the nurse expect to find the fundus 24 hours after delivery?

• A. At the level of the umbilicus
• B. 1 cm above the symphysis pubis
• C. At the level of the xiphoid process
• D. 2 cm below the umbilicus

Correct answer: A

Rationale: After delivery, the fundus is expected to be at the level of the umbilicus 24 hours postpartum. This position indicates that the uterus is involuting properly. Assessing the fundal height helps monitor the progress of uterine involution and can identify any potential complications like postpartum hemorrhage.

2. Which of the following is an abnormal finding when assessing the abdomen of a newborn?

• A. The umbilical cord has two arteries and one vein.
• B. The presence of green vomit.
• C. The liver is palpable 1 to 2 cm below the costal margin.
• D. The abdomen is soft and nondistended.

Correct answer: B

Rationale: The correct answer is B. The presence of green vomit in a newborn is an abnormal finding and indicates a possible intestinal obstruction. This finding requires immediate attention and further investigation. Choices A, C, and D are normal findings in a newborn's abdomen assessment. A newborn typically has an umbilical cord with two arteries and one vein, a liver that may be palpable 1 to 2 cm below the costal margin due to its normal size in a neonate, and a soft, nondistended abdomen as expected in healthy newborns.

3. A 3-year-old is seen in the clinic and is diagnosed with an ear infection. The father reports that the child was awake several times during the night, crying. The PRIORITY nursing diagnosis for this child is:

• A. Sleep Pattern Disturbance related to pain.
• B. Pain related to ear infection.
• C. Altered Family Processes related to ill child.
• D. Ineffective Thermoregulation Related to Infection

Correct answer: B

Rationale: The priority nursing diagnosis for a child diagnosed with an ear infection and experiencing nighttime awakenings and crying would be 'Pain related to ear infection.' Pain management is crucial to ensure the child's comfort and well-being, which can also impact their sleep patterns. Addressing the pain as a priority can lead to improved sleep and overall recovery for the child.

4. An 18-month-old child presents with fever, nasal flaring, intercostal retractions, and a respiratory rate of 50 bpm. What is the most appropriate nursing diagnosis?

• A. High risk for altered body temperature - hyperthermia
• B. Ineffective breathing pattern
• C. Ineffective individual coping
• D. Knowledge deficit

Correct answer: B

Rationale: In this case, the child is showing signs of respiratory distress, such as nasal flaring, intercostal retractions, and an increased respiratory rate. These are indicative of an ineffective breathing pattern. The child's compromised respiratory function requires immediate attention and intervention, making 'Ineffective breathing pattern' the most appropriate nursing diagnosis. Choices A, C, and D do not address the respiratory distress the child is experiencing and are not the priority in this situation.

5. Which of the following is not an infectious cause of diarrhea?

• A. Allergy
• B. Bacteria
• C. Parasite
• D. Virus

Correct answer: A

Rationale: The correct answer is A: Allergy. Allergy is not an infectious cause of diarrhea. Diarrhea caused by bacteria, parasites, and viruses is due to infection, while an allergy triggers an immune response that can lead to diarrhea but is not caused by an infectious agent. Choices B, C, and D are incorrect because bacteria, parasites, and viruses are known infectious causes of diarrhea, resulting from infections by these microorganisms.

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