Nursing Elites

1. Which observation of the exposed abdomen is most indicative of pyloric stenosis?

• A. abdominal rigidity
• B. substernal retraction
• C. palpable olive-like mass
• D. marked distention of the lower abdomen

Correct answer: C

Rationale: In pyloric stenosis, a palpable olive-like mass in the abdomen is a classic finding. This mass is due to the hypertrophied pyloric muscle. Abdominal rigidity (choice A) is associated with conditions like peritonitis, substernal retraction (choice B) is typically seen in respiratory distress, and marked distention of the lower abdomen (choice D) is more characteristic of conditions like intestinal obstruction rather than pyloric stenosis.

2. A child with a diagnosis of pyloric stenosis is scheduled for surgery. What preoperative intervention is important for the nurse to perform?

• A. Administering intravenous fluids
• B. Monitoring for signs of infection
• C. Monitoring for signs of dehydration
• D. Monitoring for signs of pain

Correct answer: C

Rationale: The correct preoperative intervention for a child with pyloric stenosis is to monitor for signs of dehydration. Pyloric stenosis can lead to vomiting, which can result in dehydration. Monitoring for signs of dehydration is crucial to ensure the child's fluid balance is maintained. Administering intravenous fluids, although important for managing dehydration and electrolyte imbalances, would typically be done postoperatively rather than as a preoperative intervention. Monitoring for signs of infection is important but not specific to the preoperative period for pyloric stenosis. Monitoring for signs of pain is also important but may not be the most critical preoperative intervention in this scenario.

3. Your assessment of a mother in active labor reveals that a limb is protruding from the vagina. Management of this condition should include:

• A. Positioning the mother in a semi-Fowler's position, administering oxygen, and providing transport
• B. Positioning the mother in a head-down position with her hips elevated, administering oxygen, and providing transport
• C. Applying gentle traction to the protruding limb to remove pressure of the fetus from the umbilical cord
• D. Giving the mother 100% oxygen and attempting to manipulate the protruding limb so that delivery can occur

Correct answer: B

Rationale: In a situation where a limb is protruding from the vagina during active labor, the correct management includes positioning the mother in a head-down position with her hips elevated. This position helps relieve pressure on the umbilical cord and improves oxygenation to the fetus. Administering oxygen is important to ensure adequate oxygen supply to both the mother and the baby. Providing transport is necessary for prompt transfer to a medical facility for further management. Applying gentle traction to the protruding limb is not recommended as it can cause harm to the baby and should be avoided. Giving 100% oxygen and attempting to manipulate the protruding limb is not the correct approach and can potentially lead to further complications.

4. The nurse is assessing a 4-year-old client. Which finding suggests to the nurse this child may have a genetic disorder?

• A. The inquiry determines the child had feeding problems.
• B. The child weighs 40 lb (18.2 kg) and is 40 in (101.6 cm) in height.
• C. The child has low-set ears with lobe creases.
• D. The child can hop on one foot but cannot skip.

Correct answer: C

Rationale: Low-set ears with lobe creases are often associated with genetic disorders, such as Down syndrome, and can indicate underlying chromosomal abnormalities. This physical characteristic is a common feature seen in various genetic syndromes. The other choices, including feeding problems, weight and height measurements, and motor skills, are not typically specific indicators of genetic disorders in the absence of other associated features.

5. A child with a diagnosis of diabetes insipidus is admitted to the hospital. What is the priority nursing intervention?

• A. Administering insulin
• B. Monitoring fluid balance
• C. Administering diuretics
• D. Monitoring vital signs

Correct answer: B

Rationale: The correct priority nursing intervention for a child diagnosed with diabetes insipidus is to monitor fluid balance. Diabetes insipidus is a condition characterized by excessive urination and thirst, which can lead to dehydration. Monitoring fluid balance is essential to prevent dehydration and ensure the child's hydration status remains stable. Administering insulin (Choice A) is not indicated in diabetes insipidus because it is a disorder of the posterior pituitary gland, not the pancreas. Administering diuretics (Choice C) would exacerbate fluid loss in a child already at risk for dehydration. Monitoring vital signs (Choice D) is important but not the priority when compared to maintaining fluid balance in a child with diabetes insipidus.

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