you are assessing sexual maturity levels which tool do you expect to use
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Nursing Elites

ATI RN

ATI Nursing Care of Children

1. In assessing sexual maturity levels, which tool would you expect to use?

Correct answer: B

Rationale: The correct answer is B: Tanner staging. Tanner staging is a tool specifically used to assess sexual maturity in adolescents based on the development of secondary sexual characteristics. The Tanner scale ranges from stage 1 (prepubertal) to stage 5 (adult maturity). This tool helps healthcare providers evaluate the physical development and sexual maturation of individuals. Choice A, the Denver II Developmental Screening, is used to assess developmental milestones in children. Choice C, antibody testing, is a diagnostic tool used to detect the presence of specific antibodies in the blood. Choice D, the nursing process, is a systematic method that nurses use to deliver patient-centered care, involving assessment, diagnosis, planning, implementation, and evaluation.

2. What is an appropriate screening test for hearing that the nurse can administer to a 5-year-old child?

Correct answer: C

Rationale: Pure tone audiometry is an appropriate and effective screening test for hearing in a 5-year-old child, helping to assess the ability to hear various frequencies and volumes.

3. The nurse is aware that skin turgor best estimates what?

Correct answer: B

Rationale: Skin turgor is a quick and simple way to assess hydration status. Poor skin turgor can indicate dehydration.

4. Which nursing intervention should be included in the postoperative care of a child following a tonsillectomy?

Correct answer: D

Rationale: The correct answer is D: 'Avoid giving citrus juice.' Citrus juice can irritate the throat after a tonsillectomy, so it should be avoided. Choice A is incorrect because blowing the nose gently is not a recommended intervention following a tonsillectomy. Choice B is incorrect as mucus in emesis is not uncommon postoperatively and does not necessarily require physician notification. Choice C is incorrect as positioning the child supine immediately postoperatively can increase the risk of airway obstruction and should be avoided.

5. An infant is suspected of having esophageal atresia/tracheoesophageal fistula. While waiting for the pediatrician to see the infant, which action should the nurse take?

Correct answer: A

Rationale: Positioning the infant with the head of the bed elevated helps to prevent aspiration and manage secretions until further treatment can be provided. Choice B is incorrect as the priority is ensuring the infant's safety and health, not immediate bonding. Choice C is incorrect as breastfeeding may worsen the condition. Choice D is incorrect as it does not address the potential risk of aspiration associated with esophageal atresia/tracheoesophageal fistula.

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