an infant requires surgery for repair of a cleft lip an important priority of the preoperative nursing care is which
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Nursing Elites

ATI RN

Nursing Care of Children ATI

1. An infant requires surgery for repair of a cleft lip. An important priority of the preoperative nursing care is which?

Correct answer: B

Rationale: Performing a baseline physical and behavioral assessment is crucial to determine the infant's current health status and to identify any potential risks before surgery.

2. The nurse is admitting a 9-year-old child with hemolytic uremic syndrome. What clinical manifestations should the nurse expect to observe? (Select all that apply.)

Correct answer: A

Rationale: Hemolytic uremic syndrome (HUS) typically presents with hematuria, anorexia, hypertension, and purpura due to the hemolytic anemia, thrombocytopenia, and renal failure that characterize this condition.

3. Nurses should be alert for increased fluid requirements in which circumstance?

Correct answer: A

Rationale: Fever increases metabolic rate, leading to insensible water loss, thus requiring increased fluid intake. Mechanical ventilation, CHF, and increased intracranial pressure generally require fluid restriction rather than increased fluid intake.

4. At what age is it safe to give infants whole milk instead of commercial infant formula?

Correct answer: C

Rationale: Whole milk should not be introduced before 12 months because it lacks the necessary nutrients, such as iron, that infants need for proper growth and development.

5. When assessing an infant with intussusception, what type of stool would the nurse expect to find?

Correct answer: B

Rationale: The correct answer is B: Currant-jelly stool. This type of stool, which is red and mucous-like, is a classic sign of intussusception in infants. Choice A (Soft, seedy stool) is incorrect as it does not specifically describe the characteristic stool associated with intussusception. Choice C (Ribbon-like stool) is incorrect; ribbon-like stool may be seen in conditions like colon cancer, not intussusception. Choice D (Soft and pasty stool) is also incorrect as it does not match the typical stool finding in intussusception.

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