Nursing Elites

1. Which reflex is expected to disappear by 4 months of age?

• A. Rooting reflex
• B. Moro reflex
• C. Babinski reflex
• D. Palmar grasp

Correct answer: B

Rationale: The Moro reflex, also known as the startle reflex, typically disappears by 4 months as the infant's nervous system matures. This reflex is important for assessing the development of the nervous system in newborns. The Rooting reflex (Choice A) is related to turning the head in response to cheek stimulation; the Babinski reflex (Choice C) involves the fanning of toes in response to foot stimulation; and the Palmar grasp (Choice D) is the curling of the fingers around an object placed in the infant's hand. These reflexes have different timelines for disappearance and are not typically expected to be gone by 4 months of age.

2. In what condition should the nurse be alert for altered fluid requirements in children? (Select all that apply.)

• A. Oliguric renal failure
• B. Increased intracranial pressure
• C. Mechanical ventilation
• D. All above

Correct answer: D

Rationale: Conditions like oliguric renal failure, increased intracranial pressure, and mechanical ventilation significantly alter fluid requirements in children. These conditions either restrict fluid output or require careful fluid management to avoid worsening the condition.

3. An infant is diagnosed with a tracheoesophageal fistula. Which assessment finding should the nurse expect?

• A. Jaundice
• B. Hyperactive bowel sounds
• C. Absence of sucking, vomiting
• D. Coughing, with excessive secretion

Correct answer: D

Rationale: Coughing with excessive secretion is a common sign of tracheoesophageal fistula. In this condition, the connection between the trachea and esophagus allows saliva and food to enter the airways, leading to coughing and excessive secretions. Choice A, jaundice, is not typically associated with tracheoesophageal fistula. Hyperactive bowel sounds (Choice B) are more likely seen in conditions like gastroenteritis. Absence of sucking and vomiting (Choice C) is not a typical finding related to tracheoesophageal fistula.

4. The nurse is performing an oral examination on a preschool child. Which strategies should the nurse use to encourage the child to open the mouth for the examination? (Select all that apply.)

• A. Lightly brush the palate with a cotton swab
• B. Perform the examination in front of a mirror
• C. Let the child examine someone else's mouth first
• D. All of the above

Correct answer: D

Rationale: Using a cotton swab, allowing the child to observe, and demonstrating on someone else are effective ways to encourage a preschooler to open their mouth for examination.

5. The mother of a 6-month-old infant has returned to work and is expressing breast milk to be frozen. She asks for directions on how to safely thaw the breast milk in the microwave. What should the nurse recommend?

• A. Heat only 10 oz or more.
• B. Do not thaw or heat breast milk in a microwave oven.
• C. Always leave the bottle top uncovered to allow heat to escape.
• D. Shake the bottle vigorously for at least 30 seconds after heating.

Correct answer: B

Rationale: Thawing or heating breast milk in a microwave is not recommended because it can create hot spots that may burn the infant and destroy essential nutrients.

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