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. A breastfed infant is being seen in the clinic for a 6-month checkup. The mother tells the nurse that the infant recently began to suck her thumb. Which is the best nursing intervention?

Correct answer: A

Rationale: Thumb sucking is a normal self-soothing behavior in infants and usually does not indicate a problem. Reassuring the mother that this is normal is the appropriate response.

3. A mother delivers an infant at 30 weeks gestation. The mother asks the nurse for information on nutrition and if formula would be better since the baby is premature. What is the foundation for the response to the mother by the nurse?

Correct answer: A

Rationale: The correct answer is A. Human milk is the preferred food for infants, including preterm infants. It contains essential ingredients necessary for the infant's growth and development. The mother should pump her breasts to provide milk for the infant if the child is receiving enteral feedings. Once the infant can coordinate breathing, sucking, and swallowing, breastfeeding directly is encouraged. Studies have shown that preterm infants fed fortified human milk have better outcomes compared to those fed commercial infant formulas. Commercial infant formulas may not fully meet the unique nutritional needs of preterm infants, leading to potential longer hospital stays. Therefore, human milk is the best choice for feeding premature infants.

4. Which pediatric condition is characterized by a "string sign" on an upper GI series?

Correct answer: B

Rationale: The correct answer is B: Hypertrophic pyloric stenosis. The "string sign" is associated with hypertrophic pyloric stenosis, a condition where the pyloric canal is narrowed, leading to gastric outlet obstruction. Intussusception (choice A) typically presents with colicky abdominal pain and currant jelly stools. Hirschsprung disease (choice C) is characterized by the absence of ganglion cells in the distal colon. Meckel diverticulum (choice D) is a congenital outpouching of the small intestine that can present with painless rectal bleeding.

5. When assessing a family, the nurse determines that the parents exert little or no control over their children. This style of parenting is called which?

Correct answer: A

Rationale: Permissive parenting is characterized by parents exerting little or no control over their children, leading to a lack of boundaries and structure.

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