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. The nurse is teaching a parent of a 6-month-old infant with gastroesophageal reflux (GER) before discharge. What instructions should the nurse include?

Correct answer: D

Rationale: Cimetidine is an H2 blocker that reduces stomach acid, helping manage GER. Holding the infant in the prone position is not recommended due to the risk of SIDS. Breastfeeding should not be discontinued unless advised by a physician. Elevating the head to 90 degrees is excessive.

3. A sixteen-year-old boy is diagnosed with osteosarcoma. What information should the nurse know regarding the treatment plan?

Correct answer: C

Rationale: Osteosarcoma is typically treated with a combination of surgery and chemotherapy. This approach aims to remove the tumor and reduce the risk of metastasis. Amputation of the affected extremity may be necessary in some cases to ensure complete removal of the tumor. Intensive radiation is not the primary treatment for osteosarcoma, and bone marrow transplantation is not the standard treatment for this type of cancer.

4. What condition is often associated with severe diarrhea?

Correct answer: A

Rationale: Severe diarrhea can lead to a loss of bicarbonate, resulting in metabolic acidosis. This is a common complication of prolonged or severe diarrhea, especially in children.

5. Children may believe that they are responsible for their parents' divorce and interpret the separation as punishment. At which age is this most likely to occur?

Correct answer: C

Rationale: At around 8 years old, children may feel they are responsible for their parents' divorce and view it as a punishment, which can impact their emotional well-being.

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