a thorough systemic physical assessment is necessary in the extremely low birth weight elbw infant to detect what
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Nursing Elites

ATI RN

ATI Nursing Care of Children

1. A thorough systemic physical assessment is necessary in the extremely low-birth-weight (ELBW) infant to detect what?

Correct answer: C

Rationale: In extremely low-birth-weight (ELBW) infants, a thorough systemic physical assessment is crucial to detect subtle changes that may indicate an underlying problem. These infants are highly vulnerable and may show signs of stress through changes in feeding behavior, activity, color, oxygen saturation, or vital signs. Monitoring weight in ELBW infants primarily reflects genitourinary function rather than fluid retention. Difficulties in maternal-child attachment are important but are usually assessed during parental visits and are not the primary focus of a systemic physical assessment. Changes in the Apgar score are used immediately after birth to assess the transition to extrauterine life and are not as relevant in the following 24 hours to detect ongoing subtle issues.

2. The nurse is talking to a group of parents of school-age children at an after-school program about childhood health problems. Which statement should the nurse include in the teaching?

Correct answer: A

Rationale: Childhood obesity is the most common nutritional problem in children, with significant implications for long-term health, including the risk of developing chronic diseases.

3. What findings would the nurse consider normal in assessing the anterior fontanel of a neonate?

Correct answer: D

Rationale: The correct answer is D: Pulsating anterior fontanel. The fontanel should feel flat, firm, and well demarcated. Pulsations are frequently visible at the anterior fontanel, which is a normal finding in a neonate. A closed anterior fontanel, as mentioned, is a potential sign of a major abnormality. A sunken or bulging fontanel (when the infant is quiet) may be indicative of distress or a major abnormality. Therefore, options A, B, and C are considered abnormal findings when assessing the anterior fontanel of a neonate.

4. What urine test result is considered abnormal?

Correct answer: A

Rationale: A urine pH of 4.0 is abnormally low, indicating possible acidosis or other metabolic conditions. WBC count of 1-2 cells/ml, absence of protein, and a specific gravity of 1.020 are within normal limits.

5. Which is considered a block to effective communication?

Correct answer: B

Rationale: Using clichés is a communication block because it can come across as dismissive or insincere, hindering meaningful dialogue.

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