ATI RN
Nursing Care of Children ATI
1. The nurse is assessing a 3-day-old breastfed newborn who weighed 3400 g (7 pounds, 8 oz) at birth. The infant’s mother is now concerned because the infant weighs 3147 g (6 pounds, 15 oz). The most appropriate nursing intervention is what?
- A. Recommend supplemental feedings of formula.
- B. Explain that this weight loss is within normal limits.
- C. Assess the child further to determine the cause of excessive weight loss.
- D. Encourage the mother to express breast milk for bottle-feeding the infant.
Correct answer: B
Rationale: A neonate normally loses about 10% of the birth weight by age 3 to 4 days. The birth weight is usually regained by the 10th day of life. In this case, the weight loss from 3400 g to 3147 g is within the expected range. Therefore, the most appropriate action is to explain to the mother that this weight loss is within normal limits. Choice A is incorrect because supplemental feedings of formula are not indicated for this expected weight loss in a breastfed newborn. Choice C is incorrect as there is no evidence to suggest excessive weight loss at this point. Choice D is unnecessary at this stage and may not align with the current situation of normal weight loss post-birth.
2. An adolescent states, “I want to be a doctor or a lawyer when I grow up because I like taking care of people.” Which Eriksonian challenge is the adolescent attempting?
- A. Identity vs. role diffusion
- B. Trust vs. mistrust
- C. Industry vs. inferiority
- D. Autonomy vs. shame and doubt
Correct answer: A
Rationale: The correct answer is A: Identity vs. role diffusion. During adolescence, individuals face the challenge of forming a cohesive sense of self and identity. In this scenario, the adolescent's desire to become a doctor or lawyer reflects the exploration of potential roles and career paths, indicating an attempt to establish a clear identity. Choices B, C, and D are incorrect. Trust vs. mistrust is a challenge experienced in infancy, industry vs. inferiority is relevant to the school-age period, and autonomy vs. shame and doubt is associated with the toddler stage, not adolescence.
3. A 12-month-old infant has been diagnosed with failure to thrive (FTT). Which assessment findings does the nurse expect to be documented with this infant?
- A. Fear of strangers
- B. Minimal smiling
- C. Avoidance of eye contact
- D. All of the above
Correct answer: D
Rationale: These behaviors are consistent with FTT and indicate social withdrawal, which is often observed in infants who are not thriving. A wide-eyed gaze and avoidance of eye contact can also indicate developmental delays or emotional disturbances.
4. The parent of an 8.2-kg (18-lb) 9-month-old infant is borrowing a federally approved car seat from the clinic. The nurse should explain that the safest way to put in the car seat is what?
- A. Front facing in back seat
- B. Rear facing in back seat
- C. Front facing in front seat with air bag on passenger side
- D. Rear facing in front seat if an air bag is on the passenger side
Correct answer: B
Rationale: Infants should be placed rear-facing in the back seat until they are at least 2 years old or exceed the weight/height limit of their car seat for optimal safety.
5. Why are neonates predisposed to problems with thermoregulation?
- A. Renal function is not fully developed
- B. Flexed posture favors heat loss
- C. A large body surface area favors heat loss to the environment
- D. A thick layer of subcutaneous fat provides excellent insulation
Correct answer: C
Rationale: Newborns have a large surface area relative to their body weight, making them more susceptible to heat loss and requiring careful thermoregulation. Choice A is incorrect because renal function is not directly related to thermoregulation. Choice B is incorrect because a flexed posture actually helps reduce heat loss by minimizing the surface area exposed to the environment. Choice D is incorrect because neonates have limited subcutaneous fat, which contributes to their susceptibility to heat loss.
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