Nursing Elites

1. During the initial assessment of the newborn, which of the following data would be considered normal?

• A. Chest circumference 31.5 cm, head circumference 33.5 cm
• B. Chest circumference 30 cm, head circumference 29 cm
• C. Chest circumference 38 cm, head circumference 31.5 cm
• D. Chest circumference 32.5 cm, head circumference 36 cm

Correct answer: A

Rationale: The correct answer is A. During the initial assessment of a newborn, the average head circumference at birth is 32 to 37 cm, while the average chest circumference ranges from 30 to 35 cm. Normally, the head's circumference is about 2 cm greater than the chest circumference at birth. Choice A provides measurements of chest circumference 31.5 cm and head circumference 33.5 cm, both falling within the normal range in terms of actual size and relative size. Choices B, C, and D do not align with the typical measurements seen in a healthy newborn. Choice B has both circumferences below the average range, choice C has the chest circumference above the average, and choice D has the head circumference notably higher than the chest circumference, which is not typical for a newborn.

2. Which of the following is the MOST detrimental effect of gastric distention in infants and children?

• A. Tracheal rupture.
• B. Less effective chest compressions.
• C. Decreased ventilatory volume.
• D. Acute rupture of the diaphragm.

Correct answer: C

Rationale: Gastric distention in infants and children can lead to a decrease in ventilatory volume. This occurs because the distended stomach can limit the movement of the diaphragm, reducing its ability to contract and expand the chest cavity effectively. As a result, the amount of air entering and leaving the lungs is decreased, impacting ventilation. Tracheal rupture, acute rupture of the diaphragm, and less effective chest compressions are not typically associated with gastric distention.

3. A 3-month-old is hospitalized with a fractured femur. The pain assessment tool most appropriate for this child is the:

• A. FLACC scale.
• B. Poker chip tool.
• C. Number scale.
• D. Visual analog scale.

Correct answer: A

Rationale: The FLACC scale is a validated pain assessment tool suitable for infants and young children, including 3-month-olds. It assesses pain based on five categories: Face, Legs, Activity, Cry, and Consolability. Since infants cannot communicate their pain verbally, the FLACC scale is effective in evaluating pain by observing these behavioral indicators. The other options, such as the Poker chip tool, Number scale, and Visual analog scale, are not specifically designed for infants and may not provide accurate pain assessment in this age group.

4. Based on the complaints provided by Madam KK, is the child exhibiting danger signs?

• A. Yes
• B. No
• C. I don't know
• D. Yes

Correct answer: A

Rationale: Yes, the child is displaying danger signs with symptoms such as fever and rapid breathing, indicating a potential serious health issue that requires immediate attention. The correct answer is 'Yes' because the symptoms described in Madam KK's complaints align with danger signs that suggest a severe health problem. Choices B and C are incorrect because the symptoms mentioned clearly indicate the presence of danger signs. Choice D is a duplicate of choice A and does not provide a valid alternative.

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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