Nursing Elites

1. The parent of a 2-week-old infant asks the nurse if fluoride supplements are necessary because the infant is exclusively breastfed. What is the nurse's best response?

• A. The infant needs to begin taking them now.
• B. Supplements are not needed if you drink fluoridated water.
• C. The infant may need to begin taking them at age 6 months.
• D. The infant can have infant cereal mixed with fluoridated water instead of supplements.

Correct answer: C

Rationale: Breastfed infants may need fluoride supplements starting at 6 months if they are not receiving fluoride from other sources, such as drinking water.

2. Which sign is indicative of developmental dysplasia of the hip in infants?

• A. Ortolani sign
• B. Romberg sign
• C. Trendelenburg sign
• D. Gower's sign

Correct answer: A

Rationale: The Ortolani sign is a specific maneuver used during physical examination to detect hip instability or dislocation in infants. A positive Ortolani sign, where the hip is felt to slip back into the socket, is indicative of developmental dysplasia of the hip, a condition that can lead to long-term disability if not treated early. Romberg sign is used to assess sensory ataxia, Trendelenburg sign indicates weakness of the hip abductor muscles, and Gower's sign is seen in children with proximal muscle weakness climbing up their own body from a supine position due to conditions like muscular dystrophy.

3. The nurse is teaching parents about expected language development for their 6-month-old infant. The nurse recognizes the parents understand the teaching if they make which statement?

• A. Our baby should comprehend the word no.
• B. Our baby knows the meaning of saying mama.
• C. Our baby should be able to say three to five words.
• D. Our baby should begin to combine syllables, such as dada.

Correct answer: D

Rationale: At 6 months, infants typically begin to combine syllables like "dada" or "mama," but they do not yet understand the meaning of these words.

4. The child is admitted with acute abdominal pain and possible appendicitis. What intervention is appropriate to relieve the abdominal discomfort during the evaluation?

• A. Place the child in the Trendelenburg position.
• B. Apply moist heat to the abdomen.
• C. Allow the child to assume a position of comfort.
• D. Administer a saline enema to cleanse the bowel.

Correct answer: C

Rationale: Allowing the child to assume a position of comfort is appropriate as it helps alleviate discomfort without the risk of complications. Placing the child in the Trendelenburg position could increase intra-abdominal pressure and worsen the condition. Applying moist heat may lead to vasodilation and potential perforation in case of appendicitis. Administering a saline enema can be harmful if the appendix is inflamed or perforated.

5. Which distraction technique should be used for an adolescent child during a painful procedure?

• A. Blowing bubbles
• B. Guided imagery
• C. EMLA cream
• D. Sucrose solution

Correct answer: B

Rationale: The correct answer is B: Guided imagery. Guided imagery is an effective distraction technique for adolescents as it helps them focus on positive mental images instead of the pain. This technique can be a powerful tool in managing pain and anxiety during procedures. Blowing bubbles (choice A) may be more suitable for younger children as it can engage them visually and help distract them. EMLA cream (choice C) is a topical anesthetic and not a distraction technique. Sucrose solution (choice D) is used for pain relief in infants, not typically for adolescents undergoing painful procedures.

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