a new parent when asked by a nurse explains that the 4 month old infant has been nursing regularly every 3 to 4 hours and seems satisfied however the

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Nursing Care of Children ATI

1. A new parent, when asked by a nurse, explains that the 4-month-old infant has been nursing regularly every 3 to 4 hours and seems satisfied. However, the parent recently introduced solid food in the form of unbuttered popcorn to the infant as a supplement. What should be the primary nursing concern in this situation?

A. Imbalanced nutrition, more than body requirements, related to introduction of a high-calorie food
B. Risk for aspiration related to feeding the infant an inappropriate food
C. Imbalanced nutrition, less than body requirements, related to introduction of a low-nutritive food
D. Readiness for enhanced nutrition, related to the age of the infant

Correct answer: B

Rationale: The primary nursing concern in this situation is the risk for aspiration. Popcorn is a choking hazard for infants, as their airway is not fully developed to handle solid foods like popcorn. Choices A, C, and D are incorrect because the main focus should be on the immediate risk of aspiration due to the inappropriate solid food given to the infant, rather than on nutritional imbalances or readiness for enhanced nutrition.

2. 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?

A. Recheck head control at the next visit
B. Teach the parents appropriate exercises
C. Schedule the child for further evaluation
D. Refer the child for further evaluation if the anterior fontanel is still open

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.

3. When auscultating an infant's lungs, the nurse detects diminished breath sounds. What should the nurse interpret this as?

A. Suggestive of chronic pulmonary disease
B. Suggestive of impending respiratory failure
C. An abnormal finding warranting investigation
D. A normal finding in infants younger than 1 year of age

Correct answer: C

Rationale: Diminished breath sounds in an infant are an abnormal finding and warrant further investigation to rule out conditions like atelectasis or pneumonia.

4. A school-age child is admitted to the pediatric unit with a vaso-occlusive crisis. Which of these should be included in the nursing plan of care?

A. Correction of alkalosis
B. Pain management and administration of heparin
C. Adequate oxygenation and replacement of factor VIII to correct the sickling
D. Adequate hydration, oxygenation, and pain management

Correct answer: D

Rationale: The correct answer is D. Vaso-occlusive crises in sickle cell anemia require a comprehensive approach that includes adequate hydration to reduce blood viscosity, oxygenation to prevent further sickling of red blood cells, and aggressive pain management. This approach helps improve tissue perfusion and manage pain effectively. Choices A, B, and C are incorrect. Correction of alkalosis is not a priority in vaso-occlusive crisis management. Administration of heparin is not indicated as it can increase the risk of bleeding in sickle cell patients. Factor VIII replacement is not relevant to sickle cell anemia as it is a treatment for hemophilia, not sickle cell disease.

5. Nursing care of children focuses on improving quality by:

A. Improving sanitation
B. Focusing on curing childhood illnesses
C. Addressing problems caused by communicable disease
D. Providing a holistic environment for optimal growth and development

Correct answer: D

Rationale: The correct answer is D because nursing care for children should encompass a holistic approach that considers not only physical health but also emotional, social, and developmental aspects. Providing a holistic environment promotes optimal growth and development by addressing all these dimensions. Choices A, B, and C are incorrect because while sanitation, curing illnesses, and addressing communicable diseases are important aspects of child healthcare, they do not encompass the comprehensive care provided by a holistic approach.