ATI RN
RN Nursing Care of Children 2019 With NGN
1. Apgar scoring is conducted at 1 minute and 5 minutes after birth. It is used to determine:
- A. Major body systems’ responses at birth
- B. Future intelligence of the newborn
- C. Level of parent and newborn interaction
- D. Gestational age of the newborn
Correct answer: A
Rationale: The Apgar score assesses a newborn's physical condition immediately after birth by evaluating heart rate, respiratory effort, muscle tone, reflex response, and color. Therefore, the correct answer is A. The other choices are incorrect because B) the Apgar score does not predict future intelligence, C) it does not measure parent and newborn interaction, and D) it is not used to determine gestational age.
2. What is the most appropriate nursing action when intermittently gavage feeding a preterm infant?
- A. Allow formula to flow by gravity
- B. Avoid allowing the infant to suck on the tube
- C. Insert the tube through the nares instead of the mouth
- D. Apply gentle pressure to the syringe to deliver the formula
Correct answer: A
Rationale: The correct action when intermittently gavage feeding a preterm infant is to allow the formula to flow by gravity. This method helps prevent overfeeding and aspiration, which can occur if the formula is delivered too quickly under pressure. Choice B is incorrect as sucking on the tube can cause complications. Choice C is incorrect as the tube is typically inserted through the mouth. Choice D is incorrect as steady pressure can lead to rapid delivery of the formula, increasing the risk of complications.
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?
- A. Implementation
- B. Planning
- C. Diagnosis
- D. Assessment
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. Melena, the passage of black, tarry stools, suggests bleeding from which source?
- A. The perianal or rectal area
- B. The upper gastrointestinal (GI) tract
- C. The lower GI tract
- D. Hemorrhoids or anal fissures
Correct answer: B
Rationale: Melena indicates bleeding from the upper GI tract. The black, tarry appearance of the stool results from the partial digestion of blood as it passes through the intestines, typically originating from sources like the stomach or duodenum. Lower GI bleeding usually presents as bright red blood in the stool, originating from sources like the colon or rectum. Choices A, C, and D are incorrect because melena specifically points to upper GI bleeding rather than issues in the perianal/rectal area, lower GI tract, or hemorrhoids/anal fissures.
5. A preschool-age child is admitted to the pediatric unit for surgery. The parents request to stay with their child. How should the nurse respond?
- A. Tell the parents they can stay in the hospital but not on the unit
- B. Read the rules and regulations of rooming in with the child
- C. Let the parents know they are allowed to stay with the child
- D. Explain to the parents why they cannot stay with the child
Correct answer: C
Rationale: The correct response is to let the parents know they are allowed to stay with the child. Allowing parents to stay with the child can help reduce the child's anxiety and provide comfort. Choice A is incorrect as the parents should be encouraged to stay with their child. Choice B is not the immediate response the nurse should provide. Choice D is inappropriate as it does not address the benefits and importance of parental presence for the child's well-being during hospitalization.
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