the nurse is caring for a child admitted with acute abdominal pain and possible appendicitis what intervention is appropriate to relieve the abdominal
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Nursing Elites

ATI RN

ATI Nursing Care of Children 2019 B

1. The child is admitted with acute abdominal pain and possible appendicitis. What intervention is appropriate to relieve the abdominal discomfort during the evaluation?

Correct answer: C

Rationale: Allowing the child to assume a position of comfort is appropriate as it helps alleviate discomfort without the risk of complications. Placing the child in the Trendelenburg position could increase intra-abdominal pressure and worsen the condition. Applying moist heat may lead to vasodilation and potential perforation in case of appendicitis. Administering a saline enema can be harmful if the appendix is inflamed or perforated.

2. The nurse is performing an otoscopic examination on a child. Which are normal findings the nurse should expect? (Select all that apply.)

Correct answer: A

Rationale: A well-defined light reflex, a small concave spot, and a grayish, nontransparent tympanic membrane are normal findings during an otoscopic examination in a child.

3. 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?

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.

4. A child diagnosed with aplastic anemia is admitted to the hospital. The parents ask the nurse what aplastic anemia is. Which response by the nurse is accurate?

Correct answer: C

Rationale: Aplastic anemia is a condition where the bone marrow fails to produce sufficient red blood cells, white blood cells, and platelets, leading to pancytopenia. This can result in fatigue, infections, and bleeding tendencies. It is not characterized by abnormal red blood cell shapes, but rather by a reduction in the production of blood cells. Therefore, the accurate response is that aplastic anemia is caused by the bone marrow producing inadequate cells. Choices A and B are incorrect as aplastic anemia does not cause a proliferation of white blood cells or involve abnormally shaped red blood cells. Choice D is incorrect as aplastic anemia is not typically a disorder that occurs after a viral illness.

5. When the nurse interviews an adolescent, which is especially important?

Correct answer: B

Rationale: Allowing adolescents to express their feelings helps them feel heard and supported, which is crucial for effective communication.

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