ATI RN
ATI Nursing Care of Children
1. What is the appropriate method for measuring the temperature of a 2-day-old neonate?
- A. Tympanic
- B. Oral
- C. Axillary
- D. Rectal
Correct answer: C
Rationale: For a 2-day-old neonate, the most suitable method to measure temperature is the axillary method. This approach is considered safe and appropriate for neonates, minimizing the risk of injury. Tympanic temperature measurement may not be as accurate in neonates due to their small ear canals. Oral temperature measurement is not recommended for neonates as they may not be able to hold a thermometer properly in their mouths. Rectal temperature measurement is invasive and carries a higher risk of injury and should be avoided unless absolutely necessary.
2. Which describe the feelings and behaviors of early preschool children related to divorce? (Select all that apply.)
- A. Regressive behavior
- B. Fear of abandonment
- C. Blame themselves for the divorce
- D. All of the above
Correct answer: D
Rationale: Preschool children may exhibit regressive behavior, fear abandonment, and blame themselves for their parents' divorce due to their limited understanding of the situation.
3. During a routine health assessment, the nurse notes that an 8-month-old infant has a significant head lag. Which is the most appropriate action?
- A. Recheck head control at the next visit
- B. Teach the parents appropriate exercises
- C. Schedule the child for further evaluation
- D. Refer the child for further evaluation if the anterior fontanel is still open
Correct answer: C
Rationale: Significant head lag at 8 months is concerning and warrants further evaluation, as it may indicate developmental delays or neurological issues.
4. After teaching a group of nursing students about developmental milestones for children between the ages of 1 and 4 years, the instructor determines that the teaching was successful when the students identify which of the following as a gross motor developmental milestone that occurs between 2 to 3 years of age?
- A. Jumping in place
- B. Climbing
- C. Standing on one foot with help
- D. Riding a tricycle
Correct answer: B
Rationale: Climbing is a gross motor milestone typically achieved between 2 to 3 years of age. It involves coordination and strength. Jumping in place is usually mastered around 2 years of age. Standing on one foot with help is a skill that emerges around 3 years. Riding a tricycle typically occurs closer to 3 years and involves coordination and balance, which are more refined skills compared to climbing at an earlier age.
5. The nurse is performing an oral examination on a preschool child. Which strategies should the nurse use to encourage the child to open the mouth for the examination? (Select all that apply.)
- A. Lightly brush the palate with a cotton swab
- B. Perform the examination in front of a mirror
- C. Let the child examine someone else's mouth first
- D. All of the above
Correct answer: D
Rationale: Using a cotton swab, allowing the child to observe, and demonstrating on someone else are effective ways to encourage a preschooler to open their mouth for examination.
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