Nursing Elites

1. While assessing an 18-month-old child, a nurse observes that the toddler can crawl upstairs but needs assistance when climbing the stairs upright. What does this action indicate to the nurse?

• A. Presence of talipes equinovarus
• B. Reflective of neurologic damage
• C. Expected behavior in a toddler of this age
• D. Existence of developmental dysplasia of the hip

Correct answer: C

Rationale: At 18 months of age, needing assistance to climb stairs upright is considered normal behavior for a toddler. Crawling upstairs is a different motor skill and does not necessarily correlate with the ability to climb stairs. The child is still developing gross motor skills, and climbing stairs upright typically requires more coordination and strength, which may not be fully developed at this age. Choices A, B, and D are not relevant in this scenario as the observed behavior is within the expected range of development for an 18-month-old child.

2. Following delivery of a newborn, the 21-year-old mother is experiencing mild vaginal bleeding. You note that her heart rate has increased from 90 to 120 beats/min and she is diaphoretic. Management should include

• A. oxygen, uterine massage, and transport
• B. oxygen, placement on the left side, and transport
• C. oxygen, treatment for shock, and uterus massage during transport
• D. oxygen, internal vaginal pads, and treatment of shock during transport

Correct answer: C

Rationale: Postpartum hemorrhage can lead to shock due to excessive bleeding. Oxygen should be provided to support oxygenation. Treatment for shock, which includes maintaining vital signs and perfusion, is crucial. Uterine massage helps prevent further bleeding by promoting uterine contraction. This combination of interventions is essential for managing postpartum hemorrhage effectively. Choices A, B, and D lack the comprehensive approach needed for managing postpartum hemorrhage, as they do not address the treatment of shock, which is vital in this scenario.

3. A parent arrives in the emergency clinic with a 3-month-old baby who says, “My baby stopped breathing for a while.” The infant continues to have difficulty breathing, with prolonged periods of apnea. Which assessment data should alert the nurse to suspect shaken baby syndrome (SBS)?

• A. Birth occurred before 32 weeks’ gestation
• B. Lack of stridor and adventitious breath sounds
• C. Previous episodes of apnea lasting 10 to 15 seconds
• D. Retractions and use of accessory respiratory muscles

Correct answer: D

Rationale: Retractions and the use of accessory respiratory muscles can be signs of respiratory distress, which may indicate trauma such as shaken baby syndrome (SBS). Shaken baby syndrome can result in brain injury and respiratory compromise, leading to breathing difficulties. Choices A, B, and C are less likely to be associated with SBS. Birth before 32 weeks’ gestation is more related to prematurity rather than SBS. The lack of stridor and adventitious breath sounds, as well as previous episodes of apnea lasting 10 to 15 seconds, are not specific indicators of SBS.

4. A nurse is planning an initial home care visit to a mother who gave birth to a high-risk infant. For what time of day should the nurse schedule the visit to be most productive?

• A. When the husband is out of the home.
• B. At a time when the mother is feeding the infant.
• C. At a time that is convenient for the family.
• D. When the nurse can spend time with the family.

Correct answer: C

Rationale: Scheduling the visit at a time that is convenient for the family is crucial for ensuring the family's receptiveness and availability, making the visit more productive. Choosing a time when the mother is feeding the infant (choice B) may not necessarily align with the family's overall convenience and may disrupt the feeding routine. Similarly, scheduling the visit when the husband is out of the home (choice A) might not be optimal as it may exclude an important family member and potentially impact the support system. While spending time with the family (choice D) is important, the primary focus should be on accommodating the family's schedule to maximize the effectiveness of the visit.

5. What finding would the nurse expect to assess in a child with hypothyroidism?

• A. Nervousness
• B. Heat intolerance
• C. Smooth velvety skin
• D. Weight gain

Correct answer: D

Rationale: Weight gain is the expected finding in a child with hypothyroidism. Hypothyroidism leads to a slowed metabolism, which can result in weight gain. Choices A, B, and C are not typical findings in hypothyroidism. Nervousness and heat intolerance are more commonly associated with hyperthyroidism, where the body is in a state of overactivity. Smooth velvety skin is not a characteristic sign of hypothyroidism.

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