ATI RN
Nursing Care of Children ATI
1. During the 2-month well-child checkup, the nurse expects the infant to respond to sound in which manner?
- A. Respond to name
- B. React to loud noise with Moro reflex
- C. Turn his or her head to side when sound is at ear level
- D. Locate sound by turning his or her head in a curving arc
Correct answer: B
Rationale: At 2 months, infants typically react to loud noises with the Moro reflex, a startle response that is normal at this stage of development.
2. Using knowledge of child development, what approach is best when preparing a toddler for a procedure?
- A. Avoid asking the child to make choices.
- B. Plan for a teaching session to last about 20 minutes.
- C. Demonstrate on a doll how the procedure will be done.
- D. Show the necessary equipment without allowing child to handle it.
Correct answer: C
Rationale: Demonstrating on a doll helps the toddler understand what will happen in a non-threatening way, making the procedure less intimidating. Long teaching sessions or avoiding choices can increase anxiety.
3. The presence of which pair of factors is a good predictor of a fluid deficit of at least 5% in an infant?
- A. Weight loss and decreased heart rate
- B. Capillary refill of less than 2 seconds and no tears
- C. Increased skin elasticity and sunken anterior fontanel
- D. Dry mucous membranes and generally ill appearance
Correct answer: D
Rationale: Dry mucous membranes and an ill appearance are good indicators of dehydration in infants, often correlating with a fluid deficit of at least 5%. Sunken fontanels and poor skin turgor are also indicative but were not options here.
4. You are developing a plan of care for a hospitalized child. Which age group is most likely to view illness as a punishment for misdeeds?
- A. Adolescence
- B. Preschool age
- C. Infancy
- D. School age
Correct answer: B
Rationale: Preschool-aged children often engage in magical thinking, where they may believe that illness is a punishment for misdeeds. This belief is related to their cognitive development stage, where they may attribute cause and effect in a magical or unrealistic way. Adolescents are more likely to view illness as a disruption to their sense of independence or control. Infants lack the cognitive development to associate illness with punishment for misdeeds. School-aged children typically have a more concrete understanding of illness and its causes, moving away from magical thinking.
5. A parent calls the hospital nursing hotline and asks, 'My 8-week-old infant cries 8 hours a day, and is hard to console. Is that normal?' What should the nurse's response be to this parent?
- A. No, call your health care provider.
- B. Let me ask you some more questions to see if there are symptoms of colic.
- C. Yes, maybe your infant is just tired.
- D. Yes, infants cry all the time at that age.
Correct answer: B
Rationale: The correct response for the nurse to provide in this situation is to ask more questions to determine if the infant is displaying symptoms of colic. Colic is a common condition in infants that can lead to prolonged crying and fussiness. It is essential to assess for other symptoms before giving advice to the parent. Choices A, C, and D are incorrect because they do not address the possibility of colic or the need for further assessment of the infant's condition.
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