Nursing Elites

1. The parents of a 3-year-old boy with Duchenne muscular dystrophy (DMD) ask, 'How can our son have this disease? We are wondering if we should have any more children.' What information should the nurse provide these parents?

• A. This is an inherited X-linked recessive disorder, which primarily affects male children in the family.
• B. The male infant had a viral infection that went unnoticed and untreated, leading to muscle damage.
• C. The lack of the protein dystrophin in the mother can impact the XXX muscle groups of males.
• D. Spinal cord damage due to birth trauma during a breech vaginal birth weakens the muscles.

Correct answer: A

Rationale: The correct answer is A. Duchenne muscular dystrophy is an X-linked recessive disorder, meaning the gene mutation causing DMD is located on the X chromosome. Males have one X chromosome and one Y chromosome, so if the X chromosome they inherit from their mother carries the mutated gene, they will develop DMD. Females have two X chromosomes, so they are carriers of the gene but are usually not affected by the disease. Therefore, the nurse should explain to the parents that DMD is an inherited X-linked recessive disorder that primarily affects male children in the family.

2. What is the priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (TE) fistula?

• A. Body temperature.
• B. Level of pain.
• C. Time of first void.
• D. Number of vessels in the cord.

Correct answer: D

Rationale: The priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (TE) fistula is to check the number of vessels in the cord. This assessment is crucial to identify any potential anomalies related to the TE fistula, as abnormalities in the cord vessels may indicate associated congenital anomalies that need immediate attention.

3. After administering the varicella vaccine to a 5-year-old child, which instruction should the nurse provide the child’s parent?

• A. Chewable children’s aspirin will not help prevent inflammation.
• B. Keep the child home for the next two days.
• C. Any fever should be monitored and reported if severe.
• D. Apply a cool pack to the injection site to reduce discomfort.

Correct answer: D

Rationale: After receiving the varicella vaccine, applying a cool pack to the injection site can help reduce discomfort. This intervention is a simple and effective way to manage local reactions at the site of the vaccination, providing comfort to the child and potentially reducing swelling or pain. Choices A, B, and C are incorrect because chewable children’s aspirin is not typically recommended after vaccination, keeping the child home is not necessary unless advised by a healthcare provider, and monitoring fever alone is not the primary instruction post-varicella vaccination.

4. A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective to prevent nipple soreness?

• A. Wear a cotton bra.
• B. Increase nursing time gradually.
• C. Correctly place the infant on the breast.
• D. Manually express a small amount of milk before nursing.

Correct answer: C

Rationale: The most effective instruction to prevent nipple soreness when breastfeeding is to correctly place the infant on the breast. Proper latch-on techniques ensure that the baby is properly positioned, reducing the risk of nipple soreness. When the baby is positioned correctly, they can nurse effectively without causing discomfort to the mother.

5. At 40-weeks gestation, a client presents to the obstetrical floor indicating that the amniotic membranes ruptured spontaneously at home. She is in active labor and feels the need to bear down and push. Which information is most important for the nurse to obtain?

• A. Color and consistency of fluid.
• B. Estimated amount of fluid.
• C. Any odor noted when membranes ruptured.
• D. Time the membranes ruptured.

Correct answer: A

Rationale: The color and consistency of the amniotic fluid are crucial to assess for the presence of meconium, which may indicate fetal distress. Meconium-stained amniotic fluid can suggest fetal compromise and the need for further evaluation and monitoring. The estimated amount of fluid is less critical than assessing for meconium. While noting any odor when the membranes ruptured may provide some information, it is not as crucial as assessing for meconium. The time the membranes ruptured is important for documenting the timeline but does not directly impact immediate patient care like assessing for fetal distress.

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