the nurse is providing anticipatory guidance to parents of a 4 month old infant on preventing an aspiration injury what should the nurse include in th
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Nursing Elites

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Nursing Care of Children ATI

1. The nurse is providing anticipatory guidance to parents of a 4-month-old infant on preventing an aspiration injury. What should the nurse include in the teaching?

Correct answer: A

Rationale: Baby powder can be inhaled by the infant and cause respiratory distress. Toys should be inspected to prevent choking hazards. Allowing an infant to take a bottle to bed can increase the risk of aspiration, and hard foods like teething biscuits should be given with caution.

2. What is an appropriate play activity for a 7-month-old infant to encourage visual stimulation?

Correct answer: A

Rationale: Playing peek-a-boo is an ideal play activity for a 7-month-old as it encourages visual tracking and social interaction, which are key developmental milestones at this age.

3. Which is a complication that can occur after abdominal surgery if pain is not managed?

Correct answer: A

Rationale: Poorly managed pain after abdominal surgery can lead to complications like atelectasis due to shallow breathing, which may occur if the child avoids deep breaths because of pain.

4. The nurse is preparing a presentation on compensated, decompensated, and irreversible shock in children. What clinical manifestations related to decompensated shock should the nurse include? (Select all that apply.)

Correct answer: A

Rationale: Decompensated shock is characterized by signs such as oliguria, confusion, pale extremities, hypotension, and a thready pulse. These indicate that the body is no longer able to maintain adequate circulation to vital organs.

5. Which congenital heart defect causes a "boot-shaped" heart on a chest x-ray?

Correct answer: A

Rationale: The correct answer is A: Tetralogy of Fallot. Tetralogy of Fallot, a congenital heart defect with four distinct abnormalities, often presents with a "boot-shaped" heart on chest x-ray due to right ventricular hypertrophy. This characteristic finding is due to the specific combination of defects in this condition. Coarctation of the aorta (choice B), Transposition of the great arteries (choice C), and Ventricular septal defect (choice D) do not typically result in a "boot-shaped" heart on a chest x-ray like Tetralogy of Fallot does.

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