a newborn is admitted to the nursery with a complete bilateral cleft lip and palate the mother refuses to see or hold her infant what should the nurse
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Nursing Elites

ATI RN

ATI Nursing Care of Children

1. A newborn is admitted to the nursery with a complete bilateral cleft lip and palate. The mother refuses to see or hold her infant. What should the nurse do first?

Correct answer: D

Rationale: In this situation, the priority is to acknowledge and validate the mother's feelings, creating a supportive environment for her. Option D is correct as it focuses on recognizing and allowing the mother to express her emotions. This approach can help build trust and facilitate communication. Options A and B are incorrect as they do not address the mother's emotional needs and may come across as dismissive. Option C is less appropriate as it only encourages expression without explicitly recognizing the mother's current emotional state.

2. What laboratory finding should the nurse expect in a child with an excess of water?

Correct answer: A

Rationale: Water excess typically leads to hemodilution, resulting in a decreased hematocrit. High serum osmolality and specific gravity would indicate dehydration, while elevated BUN could suggest renal impairment or dehydration, not fluid overload.

3. Which type of breath sound is normally heard over the entire surface of the lungs except for the upper intrascapular area and the area beneath the manubrium?

Correct answer: A

Rationale: Vesicular breath sounds are normally heard over most of the lung fields, except near the trachea and main bronchi, where bronchial or bronchovesicular sounds may be heard.

4. The parents of a child born with ambiguous genitalia tell the nurse that family and friends are asking what caused the baby to be this way. Tests are being done to assist in gender assignment. What should the nurse's intervention include?

Correct answer: A

Rationale: It is important for the nurse to provide the parents with accurate information so they can confidently explain the situation to others, helping to reduce stress and misinformation. Avoiding family and friends or minimizing the problem is not helpful.

5. A mother reports to the nurse that her 6-year-old child is highly active, irritable, irregular in habits, and adapts slowly to new routines, people, or situations. Which pattern of temperament would best describe the child?

Correct answer: B

Rationale: The 'difficult' child is the best way to describe the child in this scenario. This temperament is characterized by high activity levels, irritability, irregular habits, and difficulty adapting to changes. Choice A, the 'easy' child, is known for being generally positive and adaptable. Choice C, the 'slow-to-warm-up' child, typically needs time to adapt to new situations but is not necessarily highly active or irritable. Choice D, the 'fast-to-warm-up' child, adapts quickly to new situations, which contrasts with the child's slow adaptation mentioned in the scenario.

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