during the 2 month well child checkup the nurse expects the infant to respond to sound in which manner
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Nursing Elites

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?

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. A nurse is carrying on a conversation with a 7-year-old child during an office visit. Which is an example of the level of language development the nurse should expect in this child?

Correct answer: B

Rationale: The correct answer is B. Understanding time concepts like 'half past' can be challenging for a 7-year-old, indicating the level of language development. Choice A is incorrect as fascination with bathroom language is common in this age group but not necessarily indicative of language development. Choice C is incorrect as a 7-year-old typically cannot carry on an adult conversation due to cognitive and experiential limitations. Choice D is incorrect as by the age of 7, children should be able to speak in full sentences.

3. What is the priority nursing intervention for a child with epiglottitis?

Correct answer: B

Rationale: The correct answer is B: Maintain airway patency. When dealing with a child with epiglottitis, the priority nursing intervention is to ensure airway patency to prevent airway obstruction, which can lead to respiratory distress or failure. Administering antibiotics (choice A) is important to treat the infection, but airway management takes precedence. Providing hydration (choice C) and monitoring vital signs (choice D) are essential aspects of care but are secondary to securing the airway in a child with epiglottitis.

4. The nurse needs to take the blood pressure of a small child. Of the cuffs available, one is too large and one is too small. The best nursing action is which?

Correct answer: D

Rationale: It is essential to use the correct cuff size for accurate blood pressure readings; if the proper size is not available, it's best to wait until it can be obtained.

5. A 13-year-old boy comes to the school nurse complaining of sudden and severe scrotal pain. He denies any trauma to the scrotum. What is the most appropriate nursing action?

Correct answer: A

Rationale: Sudden and severe scrotal pain in an adolescent male is a medical emergency and may indicate testicular torsion, which requires immediate evaluation and intervention to prevent testicular loss.

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