a mother has just given birth to a newborn with a cleft lip sensing that something is wrong she starts to cry and asks the nurse what is wrong with my
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Nursing Elites

ATI RN

Nursing Care of Children ATI

1. A mother has just given birth to a newborn with a cleft lip. Sensing that something is wrong, she starts to cry and asks the nurse, "What is wrong with my baby?" What is the most appropriate nursing action?

Correct answer: A

Rationale: Encouraging the mother to express her feelings allows her to process the situation and prepares her for receiving further information in a supportive environment.

2. Which developmental milestone would the nurse expect an 11-month-old infant to have achieved?

Correct answer: A

Rationale: The correct answer is A: Sitting independently. By 11 months, most infants can sit independently. This milestone usually precedes walking, which typically occurs closer to 12 months. Turning a doorknob and building a tower of four cubes involve more complex motor skills that are typically achieved later in development. Therefore, at 11 months, sitting independently is the milestone that the nurse would expect an infant to have achieved.

3. What tool would be most useful to assess maternal and newborn attachment behaviors?

Correct answer: C

Rationale: The NCAST Feeding Scale is the most suitable tool to evaluate maternal and newborn attachment behaviors during feedings. It focuses on observing the interaction between the parent and infant, providing insights into their bonding. The Apgar score is used to assess a neonate's immediate transition to life outside the womb, not specifically maternal and newborn attachment behaviors. The Ballard scale is used to estimate gestational age, not to assess attachment behaviors. The Brazelton Neonatal Behavioral Assessment Scale is designed to evaluate a newborn's responses to various stimuli, not specifically maternal and newborn attachment behaviors.

4. The nurse is teaching parents about potential causes of colic in infancy. Which should the nurse include in the teaching session?

Correct answer: B

Rationale: Overeating, swallowing excessive air (leading to frequent burping), and parental smoking are known to contribute to colic in infants. Understimulation is not typically associated with colic.

5. A teenager is accompanied by his mother to the annual physical examination. The nurse is aware of privacy issues related to the teenager. While the mother is in the room, which topic should the nurse avoid?

Correct answer: C

Rationale: The correct answer is C: Cigarette smoking. Discussing sensitive topics like cigarette smoking in the presence of a parent may inhibit the teenager's willingness to be open and honest. It's important to provide an opportunity for the teenager to speak privately with the healthcare provider. Choices A, B, and D are more general topics that can be discussed openly in front of the parent without compromising the teenager's privacy or comfort.

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