an infant age 5 months is brought to the clinic by his parents for a well baby checkup what is the best advice that the nurse should include at this t
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Nursing Elites

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Nursing Care of Children ATI

1. An infant, age 5 months, is brought to the clinic by his parents for a well-baby checkup. What is the best advice that the nurse should include at this time about injury prevention?

Correct answer: A

Rationale: Small objects are a choking hazard for infants, so it is crucial to keep them out of reach to prevent injury.

2. What is characteristic of a neonate’s vision?

Correct answer: A

Rationale: The correct answer is A: 'Pupils react to light.' Newborns' pupils do react to light, indicating that the visual pathway is functioning. However, a neonate's vision is still developing, and they can only focus on objects close to their face. Choice B is incorrect because tear glands are functional at birth. Choice C is incorrect because the blink reflex is present in neonates and helps protect their eyes. Choice D is incorrect as neonates' ciliary muscles are not fully developed.

3. What is the most consistent and commonly used indicator of pain in infants?

Correct answer: D

Rationale: Facial expression has consistently been validated as an indicator of pain in infants. Behavioral pain measures are most reliable for sharp procedural pain in infants. Increased heart rate and respirations are indicative of a generalized and complex response to stress, not specific for pain in infants. Thrashing of arms and legs is a reliable indicator in young children, not specifically in infants.

4. The nurse is assessing a child's capillary refill time. This can be accomplished by doing what?

Correct answer: D

Rationale: Capillary refill time is assessed by applying pressure to the nail bed and observing how quickly the color returns, indicating peripheral circulation status.

5. The nurse is administering the first hepatitis A vaccine to an 18-month-old child. When should the child return to the clinic for the second dose of hepatitis A vaccination?

Correct answer: D

Rationale: The second dose of the hepatitis A vaccine is recommended 6 months after the first dose to ensure full immunity.

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