Nursing Elites

1. The nurse is preparing to administer a measles, mumps, rubella, and varicella (MMRV) vaccine. Which is a contraindication associated with administering this vaccine?

• A. The child has recently been exposed to an infectious disease
• B. The child has symptoms of a cold but no fever
• C. The child is having intermittent episodes of diarrhea
• D. The child has a disorder that causes a deficient immune system

Correct answer: D

Rationale: A compromised immune system is a contraindication for the MMRV vaccine because it is a live attenuated vaccine and could potentially cause an infection in an immunocompromised child.

2. The nurse is assessing a 3-day-old breastfed newborn who weighed 3400 g (7 pounds, 8 oz) at birth. The infant’s mother is now concerned because the infant weighs 3147 g (6 pounds, 15 oz). The most appropriate nursing intervention is what?

• A. Recommend supplemental feedings of formula.
• B. Explain that this weight loss is within normal limits.
• C. Assess the child further to determine the cause of excessive weight loss.
• D. Encourage the mother to express breast milk for bottle-feeding the infant.

Correct answer: B

Rationale: A neonate normally loses about 10% of the birth weight by age 3 to 4 days. The birth weight is usually regained by the 10th day of life. In this case, the weight loss from 3400 g to 3147 g is within the expected range. Therefore, the most appropriate action is to explain to the mother that this weight loss is within normal limits. Choice A is incorrect because supplemental feedings of formula are not indicated for this expected weight loss in a breastfed newborn. Choice C is incorrect as there is no evidence to suggest excessive weight loss at this point. Choice D is unnecessary at this stage and may not align with the current situation of normal weight loss post-birth.

3. What is a high-fiber food that the nurse should recommend for a child with chronic constipation?

• A. White rice
• B. Popcorn
• C. Fruit juice
• D. Ripe bananas

Correct answer: B

Rationale: Popcorn is a high-fiber food that can help manage chronic constipation in children. Other options like white rice and ripe bananas are low in fiber and less effective for treating constipation.

4. What is the recommended position for a child with epiglottitis to ease breathing?

• A. Supine
• B. Prone
• C. Tripod
• D. Semi-Fowler’s

Correct answer: C

Rationale: The correct answer is C, 'Tripod.' In children with epiglottitis, the tripod position is recommended to help open the airway and ease breathing. This position involves the child sitting upright, leaning forward, and supporting themselves with their hands on their knees or another surface. This posture helps improve air entry into the lungs by maximizing the space for breathing. Choices A (Supine), B (Prone), and D (Semi-Fowler’s) are incorrect. Placing a child with epiglottitis in the supine position may further obstruct the airway, while the prone position and semi-Fowler’s position do not facilitate optimal air exchange in these cases.

5. Physiologically, the child compensates for fluid volume losses by which mechanism?

• A. Inhibition of aldosterone secretion
• B. Hemoconcentration to reduce cardiac workload
• C. Fluid shift from interstitial space to intravascular space
• D. Vasodilation of peripheral arterioles to increase perfusion

Correct answer: C

Rationale: In response to dehydration, the body compensates by shifting fluids from the interstitial spaces to the intravascular space to maintain blood pressure and perfusion to vital organs. Hemoconcentration and vasoconstriction are other compensatory mechanisms but are less immediate.

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