Nursing Elites

1. What term is appropriate terminology to use for an infant whose intrauterine growth rate was slowed and whose birth weight falls below the 10th percentile on intrauterine growth charts?

• A. Postterm
• B. Postmature
• C. Low birth weight
• D. Small for gestational age

Correct answer: D

Rationale: The correct answer is D, 'Small for gestational age.' A small for gestational age, or small-for-date, infant is any child whose intrauterine growth rate was slowed and whose birth weight falls below the 10th percentile on intrauterine growth curves. Choices A and B, 'Postterm' and 'Postmature,' refer to infants born after 42 weeks of gestational age regardless of birth weight, and do not specifically address growth rate. Choice C, 'Low birth weight,' refers to infants with a birth weight less than 2500 g (5.5 pounds) regardless of gestational age, which is a different classification compared to being small for gestational age.

2. What is the primary objective of care for the child with minimal change nephrotic syndrome (MCNS)?

• A. Reduce blood pressure
• B. Lower serum protein levels
• C. Minimize excretion of urinary protein
• D. Increase the ability of tissue to retain fluid

Correct answer: C

Rationale: The primary objective in managing MCNS is to minimize the excretion of urinary protein, which is responsible for the hypoalbuminemia and subsequent edema in these patients.

3. An infant is born with anencephaly. Based on the knowledge of this diagnosis, what information does the nurse consider when interacting with the family?

• A. Many treatment options exist.
• B. Immediate surgery is necessary.
• C. The condition is incompatible with life.
• D. The child will have permanent disabilities.

Correct answer: C

Rationale: The correct answer is C: 'The condition is incompatible with life.' Anencephaly is the most serious neural tube defect where both hemispheres of the brain are absent. It is incompatible with life, as there are no medical or surgical treatment options available. While some infants with mature brain stem function can maintain vital functions for a short period, anencephaly is ultimately not survivable. Choice A is incorrect as there are no treatment options for anencephaly. Choice B is incorrect as immediate surgery is not necessary for this condition. Choice D is incorrect as an infant with anencephaly will not have permanent disabilities since the condition is not compatible with life.

4. What is a clinical manifestation of acetaminophen poisoning?

• A. Hyperpyrexia
• B. Hepatic involvement
• C. Severe burning pain in stomach
• D. Drooling and inability to clear secretions

Correct answer: B

Rationale: Acetaminophen poisoning primarily affects the liver, leading to hepatic involvement, which may present as jaundice, liver failure, or elevated liver enzymes. Hyperpyrexia, severe pain, and drooling are more associated with other types of poisoning.

5. A 5-year-old has patient-controlled analgesia (PCA) for pain management after abdominal surgery. What information does the nurse include in teaching the parents about the PCA?

• A. The child may not be pain-free.
• B. The parents or nurse may push the button for a bolus if needed.
• C. The pump allows for a continuous basal rate to deliver a constant amount of medication for pain control.
• D. Monitoring is required every 1 to 2 hours to assess patient response.

Correct answer: C

Rationale: The correct answer is C because the PCA pump can be programmed to deliver a continuous basal rate of pain medication to maintain pain control. While the goal of PCA is effective pain relief, it does not guarantee a pain-free state. In the case of a 5-year-old child, the parents or nurse can administer boluses if necessary since the child may not fully comprehend using the PCA button. Monitoring every 1 to 2 hours for patient response is adequate and there is no need for monitoring every 15 minutes, as stated in choice D, unless specific circumstances dictate more frequent monitoring.

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