the nurse is testing an infants visual acuity by which age should the infant be able to fix on and follow a target
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Nursing Elites

ATI RN

ATI Nursing Care of Children

1. The nurse is testing an infant's visual acuity. By which age should the infant be able to fix on and follow a target?

Correct answer: C

Rationale: By 3 to 4 months of age, an infant should be able to fix on and follow a target, indicating proper visual development.

2. Because children younger than 5 years are egocentric, the nurse should do which when communicating with them?

Correct answer: A

Rationale: Focusing communication directly on the child aligns with their egocentric nature and helps engage them in the conversation.

3. Melena, the passage of black, tarry stools, suggests bleeding from which source?

Correct answer: B

Rationale: Melena indicates bleeding from the upper GI tract. The black, tarry appearance of the stool results from the partial digestion of blood as it passes through the intestines, typically originating from sources like the stomach or duodenum. Lower GI bleeding usually presents as bright red blood in the stool, originating from sources like the colon or rectum. Choices A, C, and D are incorrect because melena specifically points to upper GI bleeding rather than issues in the perianal/rectal area, lower GI tract, or hemorrhoids/anal fissures.

4. The nurse notes that a child has lost 3.6 kg (8 lb) after 4 days of hospitalization for acute glomerulonephritis. What is the most likely cause of this weight loss?

Correct answer: B

Rationale: The weight loss is most likely due to the reduction of edema, as glomerulonephritis often causes fluid retention that resolves with treatment, leading to significant weight loss.

5. At what age is binocularity, the ability to fixate on one visual field with both eyes simultaneously, typically achieved?

Correct answer: B

Rationale: Binocularity, the ability to fixate on one visual field with both eyes simultaneously, is typically achieved by the age of 3 to 4 months. Achieving binocularity at 1 month is too early for most infants as their visual system is still developing. Similarly, 6 to 8 months and 12 months are beyond the normal age range for achieving binocularity, and delayed achievement could indicate potential issues like strabismus, which may lead to visual impairment if not addressed.

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