after surgery yesterday for gastroesophageal reflux the nurse finds that the infant has somehow removed the nasogastric ng tube what nursing action is
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Nursing Elites

ATI RN

ATI Nursing Care of Children 2019 B

1. After surgery yesterday for gastroesophageal reflux, the nurse finds that the infant has somehow removed the nasogastric (NG) tube. What nursing action is most appropriate to perform at this time?

Correct answer: A

Rationale: The most appropriate action for the nurse to take in this situation is to notify the healthcare provider immediately. This is important as the removal of the NG tube can disrupt postoperative care, especially in terms of maintaining gastric decompression. Inserting a new NG tube without practitioner direction can be unsafe and is not within the nurse's scope of practice. Similarly, replacing the NG tube or leaving it out should be decided by the healthcare provider to ensure the infant's safety and appropriate postoperative care.

2. What term is appropriate terminology to use for an infant whose intrauterine growth rate was slowed and whose birth weight falls below the 10th percentile on intrauterine growth charts?

Correct answer: D

Rationale: The correct answer is D, 'Small for gestational age.' A small for gestational age, or small-for-date, infant is any child whose intrauterine growth rate was slowed and whose birth weight falls below the 10th percentile on intrauterine growth curves. Choices A and B, 'Postterm' and 'Postmature,' refer to infants born after 42 weeks of gestational age regardless of birth weight, and do not specifically address growth rate. Choice C, 'Low birth weight,' refers to infants with a birth weight less than 2500 g (5.5 pounds) regardless of gestational age, which is a different classification compared to being small for gestational age.

3. Which best describes signs and symptoms as part of a nursing diagnosis?

Correct answer: D

Rationale: Signs and symptoms are cues and clusters derived from patient assessments that are used to form a nursing diagnosis, guiding the development of a care plan.

4. You are providing a home health care assessment for a very low-income mother with three young children under 5 who all appear to be at nutritional risk. Which program would you refer them to in an attempt to reduce the risk and safeguard the health of this family?

Correct answer: C

Rationale: The correct answer is C, the Supplemental Food Program for Women, Infants, and Children (WIC). WIC provides nutritional assistance to low-income pregnant women, breastfeeding women, and children under 5. The Division of Maternal and Child Health (Choice A) focuses on promoting the health of mothers and children but does not provide direct nutritional assistance. Medicaid (Choice B) is a health insurance program for low-income individuals but does not specifically address nutritional needs. The State Children’s Health Insurance Program (Choice D) provides health insurance for children in low-income families but does not offer nutritional support like WIC does.

5. The nurse is planning care for a hospitalized preschool-aged child. Which should the nurse plan to ensure atraumatic care?

Correct answer: C

Rationale: Allowing the child to make choices, such as selecting the type of juice, helps to maintain a sense of control and reduce anxiety, ensuring atraumatic care.

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