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. A child is hospitalized in acute renal failure and has a serum potassium greater than 7 mEq/L. What temporary measures that will produce a rapid but transient effect to reduce the potassium should the nurse expect to be prescribed? (Select all that apply.)

Correct answer: A

Rationale: Calcium gluconate, sodium bicarbonate, and glucose with insulin are used as temporary measures to rapidly reduce serum potassium levels. They help shift potassium into cells and stabilize the heart but do not remove potassium from the body like dialysis does.

3. The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine whether she is sexually active?

Correct answer: A

Rationale: Directly asking the adolescent if she is sexually active is the most straightforward and respectful approach, ensuring privacy and fostering trust.

4. At which age do most infants begin to fear strangers?

Correct answer: C

Rationale: Fear of strangers typically begins around 6 months as infants start recognizing familiar and unfamiliar faces, which is part of their social development.

5. At an 8-month-old well-baby visit, the parent tells the nurse that her infant falls asleep at night during the last bottle feeding but wakes up when moved to the infant’s crib. What is the most appropriate response for the nurse to make?

Correct answer: D

Rationale: Encouraging the baby to fall asleep in the crib while still awake can help establish healthy sleep habits and reduce night waking.

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