Nursing Elites

1. What is the appropriate site to administer an intramuscular (IM) vaccine to a newborn?

• A. The dorsal gluteal muscle
• B. The vastus lateralis muscle
• C. The ventral gluteal muscle
• D. The biceps muscle

Correct answer: B

Rationale: The correct site to administer an intramuscular (IM) vaccine to a newborn is the vastus lateralis muscle. For newborns, the vastus lateralis is preferred over the dorsogluteal site because the dorsogluteal site has been associated with low antibody seroconversion rates, indicating a reduced immune response. The vastus lateralis is also recommended for IM injections in newborns, while the deltoid muscle is preferred for older infants and children. The ventral gluteal muscle and the biceps muscle are not appropriate sites for IM injections. Therefore, choice B is the correct answer.

2. An infant is suspected of having esophageal atresia/tracheoesophageal fistula. While waiting for the pediatrician to see the infant, which action should the nurse take?

• A. Position the infant with the head of the bed slightly elevated
• B. Allow the infant to bond with the mother in her room
• C. Offer the infant breastfeeding instead of formula feeding
• D. Wrap the infant in blankets and place in a crib by the viewing window

Correct answer: A

Rationale: Positioning the infant with the head of the bed elevated helps to prevent aspiration and manage secretions until further treatment can be provided. Choice B is incorrect as the priority is ensuring the infant's safety and health, not immediate bonding. Choice C is incorrect as breastfeeding may worsen the condition. Choice D is incorrect as it does not address the potential risk of aspiration associated with esophageal atresia/tracheoesophageal fistula.

3. Rectal temperatures are indicated in which situation?

• A. In the newborn period
• B. Whenever accuracy is essential
• C. Rectal temperatures are never indicated
• D. When rapid temperature changes are occurring

Correct answer: B

Rationale: Rectal temperatures provide the most accurate measurement of core body temperature and are therefore indicated when accuracy is essential.

4. The nurse should assess which age group for suicide ideation since suicide in which age group is the third leading cause of death?

• A. Preschoolers
• B. Young school age
• C. Middle school age
• D. Late school age and adolescents

Correct answer: D

Rationale: Suicide is the third leading cause of death in late school-age children and adolescents, requiring careful assessment for ideation in these age groups.

5. What clinical manifestation(s) should the nurse expect to see as shock progresses in a child and becomes decompensated shock?

• A. Thirst
• B. Irritability
• C. Apprehension
• D. Confusion and somnolence

Correct answer: D

Rationale: As shock progresses and decompensation occurs, confusion and somnolence are indicative of reduced cerebral perfusion. Early signs include thirst and irritability, while confusion and altered consciousness appear as the condition worsens.

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