a nurse is planning care for a 2 month old infant who is postoperative following surgical repair of a cleft lip which of the following actions should
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Nursing Elites

ATI RN

ATI Pediatric Proctored Exam 2023

1. A nurse is planning care for a 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take?

Correct answer: D

Rationale: The nurse should keep the infant�s elbow restrained to prevent injury to the surgical site.

2. Which strategy is most effective in preventing existing challenging behaviors?

Correct answer: B

Rationale: Individualized interventions are tailored to address the specific needs and triggers of the individual's challenging behaviors. By customizing the approach to each person, it increases the likelihood of effectively preventing and managing the existing challenging behaviors.

3. When preparing an adolescent for a lumbar puncture, which of the following actions should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse when preparing an adolescent for a lumbar puncture is to apply topical analgesic cream to the site one hour before the procedure. This helps reduce pain experienced during the lumbar puncture, making the procedure more comfortable for the adolescent. Placing a cardiac monitor on the adolescent is not necessary for a lumbar puncture. Keeping the adolescent in a semi-Fowler's position for 4 hours following the procedure is not a standard practice after a lumbar puncture. Restricting fluids for 2 hours following the procedure is not a requirement for a lumbar puncture preparation.

4. At what age range is it important to feed a baby in a more upright position and no longer in sidelying?

Correct answer: B

Rationale: Feeding a baby in a more upright position and no longer in sidelying is important around 4-6 months of age. At this stage, babies start developing better head and trunk control, which allows them to sit in a more upright position for feeding, promoting safer and more efficient swallowing and digestion. Choices A, C, and D are incorrect as feeding a baby in a more upright position typically starts around 4-6 months when the baby has gained more control over their head and trunk movements, making it safer and more effective for feeding.

5. Which principle does not follow neuromaturational theory?

Correct answer: B

Rationale: Neuromaturational theory emphasizes that motor development progresses in a predictable sequence and rate, starting from primitive reflexes to voluntary control. It also states that low-level skills are foundational for higher-level skills. However, the theory does not support the idea that movement solely emerges from an interaction and cooperation of many systems, as it focuses more on the hierarchical development of motor skills.

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