ATI RN
Nursing Care of Children Final ATI
1. Which actions by the nurse demonstrate overinvolvement with patients and their families? (Select all that apply.)
- A. Buying clothes for the patients
- B. Showing favoritism toward a patient
- C. All
- D. Spending off-duty time with patients and families
Correct answer: C
Rationale: Overinvolvement includes personal actions like buying clothes, showing favoritism, and spending off-duty time with patients, which can blur professional boundaries.
2. Parents would suspect hearing loss if their child did not:
- A. Turn away from a sound
- B. Startle with sudden loud noises immediately after birth
- C. Talk at 4 months
- D. Babble at 2 months
Correct answer: D
Rationale: The correct answer is D because babbling is an early indicator of hearing ability in infants. Lack of babbling by 2 months may suggest a potential hearing issue. Choices A, B, and C are incorrect because turning away from a sound, startling with sudden loud noises immediately after birth, and talking at 4 months are not primary indicators of hearing loss in infants.
3. The nurse is assessing a 3-day-old breastfed newborn who weighed 3400 g (7 pounds, 8 oz) at birth. The infant’s mother is now concerned because the infant weighs 3147 g (6 pounds, 15 oz). The most appropriate nursing intervention is what?
- A. Recommend supplemental feedings of formula.
- B. Explain that this weight loss is within normal limits.
- C. Assess the child further to determine the cause of excessive weight loss.
- D. Encourage the mother to express breast milk for bottle-feeding the infant.
Correct answer: B
Rationale: A neonate normally loses about 10% of the birth weight by age 3 to 4 days. The birth weight is usually regained by the 10th day of life. In this case, the weight loss from 3400 g to 3147 g is within the expected range. Therefore, the most appropriate action is to explain to the mother that this weight loss is within normal limits. Choice A is incorrect because supplemental feedings of formula are not indicated for this expected weight loss in a breastfed newborn. Choice C is incorrect as there is no evidence to suggest excessive weight loss at this point. Choice D is unnecessary at this stage and may not align with the current situation of normal weight loss post-birth.
4. The nurse on a pediatric unit is writing guidelines for age-specific preparation of children for procedures based on developmental characteristics. What guideline is accurate?
- A. Inform toddlers about an upcoming procedure 2 hours before the procedure is to be performed.
- B. Inform school-age children about an upcoming procedure immediately before the procedure is scheduled to occur.
- C. Discourage parent presence during procedures on infants and toddlers.
- D. Use simple diagrams of anatomy and physiology to explain a procedure to a school-age child.
Correct answer: D
Rationale: Using simple diagrams helps school-age children understand what to expect in a procedure, catering to their developmental level and reducing anxiety. Informing toddlers too early can increase anxiety, and parents' presence is generally comforting, not discouraging.
5. Which is a complication that can occur after abdominal surgery if pain is not managed?
- A. Atelectasis
- B. Hypoglycemia
- C. Decrease in heart rate
- D. Increase in cardiac output
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.
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