which action should the nurse implement when taking an axillary temperature
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Nursing Elites

ATI RN

ATI Nursing Care of Children

1. Which action should the nurse implement when taking an axillary temperature?

Correct answer: C

Rationale: The correct technique involves placing the thermometer tip in the center of the axilla to ensure an accurate reading, with the arm held close to the body.

2. What is often the initial sign of acute rheumatic fever in children?

Correct answer: A

Rationale: Polyarthritis is indeed frequently the initial sign of acute rheumatic fever in children. It presents as joint pain, swelling, and redness. Carditis (inflammation of the heart), Erythema marginatum (a skin rash), and Sydenham chorea (involuntary muscle movements) are typically seen in the later stages of acute rheumatic fever and not as the initial sign.

3. What play activities should the nurse implement to encourage fluid intake for a child? (Select all that apply.)

Correct answer: D

Rationale: Encouraging fluid intake can be fun and engaging through activities like having a tea party, using a crazy

4. During a well-child checkup, the parent of a 5-year-old child reports the child seems much smaller than the 2 older siblings did at this same age. A review of the medical record reveals that the child is 44 inches tall and weighs 42 pounds. What information should be included in the response by the nurse?

Correct answer: D

Rationale: The correct answer is D. The child is slightly taller than average, but the weight is within normal limits. This information should be reassuring to the parent and provides insights into normal growth patterns. Choice A is incorrect as it inaccurately states that the child is taller than other children this age. Choice B is incorrect because the child's weight is actually within normal limits. Choice C is incorrect as it inaccurately states that the child is shorter in stature than other children this age.

5. In terms of gross motor development, what should the nurse expect an infant age 5 months to do?

Correct answer: C

Rationale: At 5 months, infants typically can turn from their abdomen to their back. Rolling from back to abdomen and sitting erect without support occur later.

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