the child is admitted to the hospital unit newly diagnosed with retinoblastoma which clinical manifestation does the nurse anticipate upon assessment
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Nursing Elites

ATI RN

RN Nursing Care of Children Online Practice 2019 A

1. The child is admitted to the hospital unit newly diagnosed with retinoblastoma. Which clinical manifestation does the nurse anticipate upon assessment?

Correct answer: A

Rationale: The correct answer is A: A white reflex. The 'white reflex' or leukocoria is a common sign of retinoblastoma. It occurs when the light reflects off the tumor in the eye, giving the pupil a white appearance instead of the normal red reflex. Blue-tinged sclerae (choice B) and yellow-tinged sclerae (choice D) are not typical manifestations of retinoblastoma. A red reflex (choice C) is the normal reflection seen in the eye when light is shone on it and is not associated with retinoblastoma.

2. What is the most critical physiologic change required of newborns at birth?

Correct answer: A

Rationale: The correct answer is A: Transition from fetal to neonatal breathing. The onset of breathing is the most immediate and critical physiologic change required for the transition to extrauterine life. Factors that interfere with this normal transition increase fetal asphyxia, which is a condition of hypoxemia, hypercapnia, and acidosis. While body temperature maintenance, stabilization of fluid and electrolytes, and closure of fetal shunts in the heart are crucial changes in the transition to extrauterine life, breathing and the exchange of oxygen for carbon dioxide must take precedence as they are essential for newborn survival.

3. Which are included in the evaluation step of the nursing process? (Select all that apply.)

Correct answer: A

Rationale: The evaluation step involves determining if outcomes are met, modifying the plan if needed, and selecting alternative interventions if goals are not achieved.

4. As the primary caregiver for a 5-month-old baby, according to Maslow’s hierarchy of basic needs, which intervention takes the highest priority?

Correct answer: A

Rationale: The correct answer is A: Feeding every four hours. According to Maslow’s hierarchy of needs, physiological needs, such as food, water, and warmth, take the highest priority. Ensuring that the baby is fed regularly is crucial for survival and overall health. Choice B, protection from harm, relates more to safety needs which come after physiological needs. Choice C, providing stimulation, is associated with higher-level needs like belongingness and esteem. Choice D, providing love, corresponds to esteem and self-actualization needs, which are higher in the hierarchy than physiological needs.

5. Frequent urine tests for specific gravity are required on a 6-month-old infant. What method is the most appropriate way to collect small amounts of urine for these tests?

Correct answer: C

Rationale: Aspirating urine from cotton balls inside the diaper is a minimally invasive method and effective for collecting small amounts of urine. Using a collection bag can be more cumbersome, and other methods are not as effective for this age.

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