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. What laboratory finding should the nurse expect in a child with an excess of water?

Correct answer: A

Rationale: Water excess typically leads to hemodilution, resulting in a decreased hematocrit. High serum osmolality and specific gravity would indicate dehydration, while elevated BUN could suggest renal impairment or dehydration, not fluid overload.

3. Which muscle is contraindicated for the administration of immunizations in infants and young children?

Correct answer: B

Rationale: The dorsogluteal muscle is contraindicated for immunizations in infants and young children due to the risk of injury to the sciatic nerve. The anterolateral thigh is the preferred site.

4. What clinical manifestation(s) should the nurse expect to see as shock progresses in a child and becomes decompensated shock?

Correct answer: D

Rationale: As shock progresses and decompensation occurs, confusion and somnolence are indicative of reduced cerebral perfusion. Early signs include thirst and irritability, while confusion and altered consciousness appear as the condition worsens.

5. What factor predisposes an infant to fluid imbalances?

Correct answer: C

Rationale: Infants have immature kidneys that are less efficient at concentrating urine, making them more susceptible to fluid imbalances. Their higher surface area to volume ratio also contributes to greater insensible fluid losses.

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