a parent brings the 2 year old son in for a well visit the nurse assesses his growth since the last appointment which finding should concern the nurse
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ATI RN

RN Nursing Care of Children Online Practice 2019 A

1. A parent brings their 2-year-old son in for a well visit. The nurse assesses his growth since the last appointment. Which finding should concern the nurse?

Correct answer: D

Rationale: The correct answer is D. A total weight gain of 15 lb in one year for a 2-year-old is excessive and may indicate an underlying issue such as a metabolic disorder or overfeeding. This rapid weight gain can put the child at risk for health problems. Choices A, B, and C are not typically concerning findings in a 2-year-old. A prominent abdomen can be normal at this age due to a toddler's slightly protruding belly, a forward curve of the spine at the sacral area is a typical finding in young children, and an increase in height of 5 inches in a year is within the expected range of growth for a 2-year-old.

2. Apgar scoring is conducted at 1 minute and 5 minutes after birth. It is used to determine:

Correct answer: A

Rationale: The Apgar score assesses a newborn's physical condition immediately after birth by evaluating heart rate, respiratory effort, muscle tone, reflex response, and color. Therefore, the correct answer is A. The other choices are incorrect because B) the Apgar score does not predict future intelligence, C) it does not measure parent and newborn interaction, and D) it is not used to determine gestational age.

3. 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.

4. The nurse is teaching parents about expected language development for their 6-month-old infant. The nurse recognizes the parents understand the teaching if they make which statement?

Correct answer: D

Rationale: At 6 months, infants typically begin to combine syllables like "dada" or "mama," but they do not yet understand the meaning of these words.

5. The apnea monitor alarm sounds on a neonate for the third time during this shift. What is the priority action by the nurse?

Correct answer: D

Rationale: The priority action for the nurse when the apnea monitor alarm sounds on a neonate is to assess the infant for color and the presence of respirations. This initial assessment helps determine the infant's respiratory status and the need for immediate intervention. Providing tactile stimulation or administering oxygen should only be done after assessing the infant's respiratory status. Investigating possible causes of a false alarm comes after ensuring the infant's well-being through the initial assessment.

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