Nursing Elites

1. Which muscle is contraindicated for the administration of immunizations in infants and young children?

• A. Deltoid
• B. Dorsogluteal
• C. Ventrogluteal
• D. Anterolateral thigh

Correct answer: B

Rationale: The dorsogluteal muscle is contraindicated for immunizations in infants and young children due to the risk of injury to the sciatic nerve. The anterolateral thigh is the preferred site.

2. What may be a clinical manifestation of failure to thrive (FTT) in a 13-month-old include?

• A. Irregularity in activities of daily living
• B. Preferring solid food to milk or formula
• C. Weight that is at or below the 10th percentile
• D. Appropriate achievement of developmental landmarks

Correct answer: C

Rationale: FTT is characterized by weight that falls below the 10th percentile, often accompanied by delayed developmental milestones and poor feeding habits. Regularity in activities and preference for solid food over milk or formula are less commonly associated with FTT.

3. Following treatment for iron deficiency anemia, the physician orders lab tests. Which lab value would indicate an improvement in the child’s condition?

• A. Low hemoglobin
• B. Normal platelet count
• C. High reticulocyte count
• D. Low hematocrit

Correct answer: C

Rationale: A high reticulocyte count indicates that the bone marrow is producing more red blood cells, which is a sign of recovery from anemia as the body replenishes its iron stores and increases hemoglobin levels. Low hemoglobin (Choice A) would indicate ongoing anemia rather than improvement. A normal platelet count (Choice B) and low hematocrit (Choice D) are not specific indicators of improvement in iron deficiency anemia.

4. When the nurse interviews an adolescent, which is especially important?

• A. Focus the discussion on the peer group
• B. Allow an opportunity to express feelings
• C. Use the same type of language as the adolescent
• D. Emphasize that confidentiality will always be maintained

Correct answer: B

Rationale: Allowing adolescents to express their feelings helps them feel heard and supported, which is crucial for effective communication.

5. The caregiver asks why the 6-month-old infant needs to have solid foods when breast milk is such a good source of nutrition. What would be the best response by the nurse?

• A. Solid foods, especially iron-fortified cereals, are introduced to meet the infant's increased nutritional needs, including iron, which breast milk alone may not provide adequately.
• B. The extrusion reflex must be developed and feeding solid foods will help the infant to develop this reflex.
• C. Breastfeeding will become painful when the infant gets more teeth, so the infant needs to eat solid foods.
• D. By this age the infant becomes interested in trying new skills.

Correct answer: A

Rationale: The correct response is A. Solid foods, especially iron-fortified cereals, are introduced to meet the infant's increased nutritional needs, including iron, which breast milk alone may not provide adequately. Choice B is incorrect because the extrusion reflex is related to the tongue-thrust reflex, not the nutritional needs of the infant. Choice C is incorrect as breastfeeding does not become painful when the infant gets more teeth, and it is not a reason for introducing solid foods. Choice D is incorrect as the infant's interest in trying new skills is not a primary reason for introducing solid foods at this age.

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