while making rounds the nurse observes the following client behaviors which child should the nurse further evaluate for postoperative pain
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Nursing Elites

ATI RN

RN Nursing Care of Children Online Practice 2019 A

1. While making rounds, the nurse observes the following client behaviors. Which child should the nurse further evaluate for postoperative pain?

Correct answer: D

Rationale: The correct answer is D because screaming and thrashing his arms and legs are indicative behaviors of discomfort or pain in young children. The child's actions suggest a higher likelihood of experiencing postoperative pain and necessitate further evaluation. Choices A, B, and C do not exhibit overt signs of distress or discomfort associated with pain, making them less likely candidates for postoperative pain assessment.

2. The parents of an infant with a cleft palate ask the nurse, "What follow-up care will our infant need after the repair?" Which is an accurate response by the nurse?

Correct answer: D

Rationale: After cleft palate repair, the child will need ongoing follow-up with audiologists, speech pathologists, and orthodontists to monitor hearing, speech development, and dental alignment.

3. A foster parent is talking to the nurse about the health care needs for the child who has been placed in the parent's care. Which statement best describes the health care needs of foster children?

Correct answer: B

Rationale: Foster children often have higher rates of acute and chronic health problems due to a variety of factors, including previous neglect, trauma, and inconsistent healthcare access.

4. The nurse is providing anticipatory guidance to parents of a 4-month-old infant on preventing an aspiration injury. What should the nurse include in the teaching?

Correct answer: A

Rationale: Baby powder can be inhaled by the infant and cause respiratory distress. Toys should be inspected to prevent choking hazards. Allowing an infant to take a bottle to bed can increase the risk of aspiration, and hard foods like teething biscuits should be given with caution.

5. In the newborn, into what muscle is intramuscular vitamin K administered?

Correct answer: D

Rationale: In newborns, intramuscular vitamin K is traditionally administered into the vastus lateralis muscle. This site is preferred due to its large muscle mass and accessibility. The dorsogluteal site is not recommended for newborns due to the risk of injury to the sciatic nerve. The deltoid site is also not recommended for newborns. The rectus femoris muscle is not commonly used for intramuscular injections in newborns.

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