what is the priority assessment for a nurse when caring for an infant suspected of having necrotizing enterocolitis nec
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ATI Nursing Care of Children

1. What is the priority assessment for a nurse when caring for an infant suspected of having necrotizing enterocolitis (NEC)?

Correct answer: D

Rationale: The correct answer is D: Closely monitor abdominal distention. Monitoring the abdomen for signs of distention is crucial in the early detection of necrotizing enterocolitis (NEC). In NEC, the bowel wall is edematous and breaking down, leading to abdominal distention. Holding feedings is important in the management of NEC, as feedings may need to be stopped temporarily. Checking gastric residuals before feedings helps in assessing the infant's tolerance to feedings. Taking rectal temperatures is contraindicated in NEC as it can lead to the perforation of the bowel.

2. The parents of a 4-month-old infant tell the nurse that they are getting a microwave oven and will be able to heat the baby’s formula faster. What should the nurse recommend?

Correct answer: B

Rationale: Heating formula in a plastic bottle in the microwave can cause uneven heating and release harmful chemicals from the plastic.

3. During an otoscopic examination on an infant, in which direction is the pinna pulled?

Correct answer: C

Rationale: For infants, the pinna is pulled down and back to straighten the ear canal and allow proper visualization of the tympanic membrane during otoscopic examination.

4. Which actions by the nurse demonstrate clinical reasoning? (Select all that apply.)

Correct answer: A

Rationale: Clinical reasoning involves deliberate and thoughtful decision-making, considering alternatives, and using both formal and informal data gathering methods to provide optimum care.

5. A mother brings 6-month-old Eric to the clinic for a well-baby checkup. She comments, "I want to go back to work, but I don't want Eric to suffer because I'll have less time with him." Which is the nurse's most appropriate answer?

Correct answer: C

Rationale: The best approach is to discuss childcare options that would suit Eric's needs, allowing the mother to make an informed decision without guilt or pressure.

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