an infant age 5 months is brought to the clinic by his parents for a well baby checkup what is the best advice that the nurse should include at this t
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Nursing Elites

ATI RN

Nursing Care of Children ATI

1. An infant, age 5 months, is brought to the clinic by his parents for a well-baby checkup. What is the best advice that the nurse should include at this time about injury prevention?

Correct answer: A

Rationale: Small objects are a choking hazard for infants, so it is crucial to keep them out of reach to prevent injury.

2. Congenital defects of the genitourinary tract, such as hypospadias, are usually repaired as early as possible to accomplish what?

Correct answer: D

Rationale: Early repair of congenital genitourinary defects like hypospadias is important to promote a normal body image and avoid psychological issues as the child grows. It also helps prevent urinary complications and allows for normal development.

3. During which phase of the nursing process does the nurse use essential information about the child’s physical, social, and emotional health to decide which interventions to use?

Correct answer: B

Rationale: The correct answer is B: Planning. During the planning phase of the nursing process, the nurse utilizes essential information gathered during the assessment about the child’s physical, social, and emotional health to determine the most appropriate interventions to address the identified needs. This phase focuses on developing a comprehensive care plan tailored to the individual child. A) Implementation is incorrect because this phase involves carrying out the interventions outlined in the care plan. C) Diagnosis is incorrect as it refers to identifying health issues based on the assessment data. D) Assessment is incorrect as it involves collecting and analyzing data about the child's health status, rather than deciding on interventions.

4. What is the most consistent and commonly used indicator of pain in infants?

Correct answer: D

Rationale: Facial expression has consistently been validated as an indicator of pain in infants. Behavioral pain measures are most reliable for sharp procedural pain in infants. Increased heart rate and respirations are indicative of a generalized and complex response to stress, not specific for pain in infants. Thrashing of arms and legs is a reliable indicator in young children, not specifically in infants.

5. Which physiological acid-base balance complication would be most important for the nurse to assess in a patient with diarrhea?

Correct answer: D

Rationale: The correct answer is metabolic acidosis. Diarrhea can lead to the loss of bicarbonate, causing an imbalance in the acid-base status of the body, specifically resulting in metabolic acidosis. High serum pH (choice A) is incorrect as diarrhea-induced bicarbonate loss would lower pH, not increase it. Normal serum pH (choice B) is not the best answer as diarrhea can disrupt the acid-base balance. Metabolic alkalosis (choice C) is an alkaline state, which is less likely to be caused by diarrhea.

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