during a routine health assessment the nurse notes that an 8 month old infant has a significant head lag which is the most appropriate action
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Nursing Elites

ATI RN

ATI Nursing Care of Children

1. During a routine health assessment, the nurse notes that an 8-month-old infant has a significant head lag. Which is the most appropriate action?

Correct answer: C

Rationale: Significant head lag at 8 months is concerning and warrants further evaluation, as it may indicate developmental delays or neurological issues.

2. Which immunization is typically administered at birth?

Correct answer: A

Rationale: The correct answer is A, Hepatitis B. The Hepatitis B vaccine is usually given at birth to protect against hepatitis B, a virus that can lead to chronic liver disease and liver cancer. This vaccination is crucial for newborns, especially those born to mothers who are carriers of hepatitis B. Choices B, C, and D are incorrect because DTaP (B), MMR (C), and Varicella (D) vaccines are not typically administered at birth. DTaP is given in a series starting at 2 months, MMR is usually given around 12-15 months, and Varicella is given between 12-15 months of age.

3. The nurse is seeing an adolescent and the parents in the clinic for the first time. Which should the nurse do first?

Correct answer: A

Rationale: Introducing oneself is the first step in establishing a rapport and setting a professional tone for the interaction.

4. The nurse is conducting discharge teaching with the parent of a 7-year-old child with minimal change nephrotic syndrome (MCNS). What statement by the parent indicates a correct understanding of the teaching?

Correct answer: B

Rationale: Avoiding additional salt is crucial to help manage edema in children with MCNS. While monitoring urine output is important, the other statements either misinterpret the need for prolonged school absence or misunderstand the risk associated with contact sports during steroid therapy.

5. The nurse is reviewing the Healthy People 2020 leading health indicators for a child health promotion program. Which are included in the leading health indicators? (Select all that apply.)

Correct answer: C

Rationale: Healthy People 2020 focuses on decreasing tobacco use, improving immunization rates, and increasing access to healthcare among its leading health indicators.

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