a 3 year old child was adopted immediately after birth the parents have just asked the nurse how they should tell the child that she is adopted which
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Nursing Elites

ATI RN

Nursing Care of Children Final ATI

1. A 3-year-old child was adopted immediately after birth. The parents have just asked the nurse how they should tell the child that she is adopted. Which guideline concerning adoption should the nurse use in planning a response?

Correct answer: D

Rationale: It is important to tell children about their adoption early, in an age-appropriate manner, as part of building trust and openness in the family relationship.

2. One of the most critical needs of the infant is control of body temperature. The nurse caring for a newborn warms all equipment that comes in direct contact with the newborn to help prevent which type of heat loss?

Correct answer: C

Rationale: The correct answer is Conduction (choice C). Conduction heat loss occurs when the newborn’s skin comes into direct contact with a cooler surface, so warming equipment helps prevent this. Choice A, Convection, is the transfer of heat through air or water currents, not direct contact. Choice B, Evaporation, is the loss of heat through moisture on the skin evaporating, not direct contact. Choice D, Radiation, is the transfer of heat in the form of waves or particles, not direct contact.

3. A 14-month-old child is admitted to the hospital with laryngotracheobronchitis (LTB). Which assessment findings should the nurse expect?

Correct answer: C

Rationale: The correct answer is C: 'Barking cough and inspiratory stridor.' Classic signs of laryngotracheobronchitis (LTB) include a barking cough, often described as a seal-like cough, and inspiratory stridor, which is a high-pitched sound heard during inspiration. These symptoms occur due to inflammation and narrowing of the upper airway. Choices A, B, and D are incorrect as they do not align with the typical assessment findings of LTB. Cyanosis and dyspnea (Choice A) may occur in severe cases but are not specific to LTB. Productive cough and high fever (Choice B) are more indicative of lower respiratory tract infections. Pale laryngeal and dyspnea (Choice D) are not characteristic findings of LTB.

4. Which type of breath sound is normally heard over the entire surface of the lungs except for the upper intrascapular area and the area beneath the manubrium?

Correct answer: A

Rationale: Vesicular breath sounds are normally heard over most of the lung fields, except near the trachea and main bronchi, where bronchial or bronchovesicular sounds may be heard.

5. During a routine health assessment, the nurse notes that an 8-month-old infant has a significant head lag. Which is the most appropriate action?

Correct answer: C

Rationale: Significant head lag at 8 months is concerning and warrants further evaluation, as it may indicate developmental delays or neurological issues.

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