a mother has just given birth to a newborn with a cleft lip sensing that something is wrong she starts to cry and asks the nurse what is wrong with my
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Nursing Elites

ATI RN

Nursing Care of Children ATI

1. A mother has just given birth to a newborn with a cleft lip. Sensing that something is wrong, she starts to cry and asks the nurse, "What is wrong with my baby?" What is the most appropriate nursing action?

Correct answer: A

Rationale: Encouraging the mother to express her feelings allows her to process the situation and prepares her for receiving further information in a supportive environment.

2. The nurse determines that a child's intravenous infusion has infiltrated. The infused solution is a vesicant. What is the most appropriate nursing action?

Correct answer: B

Rationale: If a vesicant solution infiltrates, stopping the infusion immediately and notifying the practitioner is critical to prevent tissue damage. Cold or warm compresses should only be applied following specific medical advice based on the vesicant involved.

3. Which is usually the only symptom of pediculosis capitis (head lice)?

Correct answer: A

Rationale: Itching is typically the primary and most common symptom of pediculosis capitis due to the lice bites on the scalp.

4. The nurse is evaluating research studies according to the GRADE criteria and has determined the quality of evidence on the subject is moderate. Which type of evidence does this determination indicate?

Correct answer: B

Rationale: Moderate evidence typically indicates that results from randomized clinical trials were inconsistent, highlighting the need for further research to confirm findings.

5. When assessing a child with chronic renal failure, which clinical manifestations would the nurse expect to find?

Correct answer: A

Rationale: When assessing a child with chronic renal failure, the nurse would expect to find uremic frost as a clinical manifestation. Uremic frost, a white powdery deposit of urea on the skin, occurs in severe cases of chronic renal failure due to the accumulation of urea and other waste products in the blood. Hypotension and massive hematuria are less common in chronic renal failure, while severe metabolic acidosis is typically mild to moderate and not a prominent clinical manifestation.

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