ATI RN
Nursing Care of Children ATI
1. An infant, age 6 months, has six teeth. The nurse should recognize that this is what?
- A. Normal tooth eruption
- B. Delayed tooth eruption
- C. Unusual and dangerous
- D. Earlier than expected tooth eruption
Correct answer: D
Rationale: Having six teeth at 6 months is earlier than the typical tooth eruption schedule, but it is not unusual or dangerous. It is within the range of normal variations in infant development.
2. Where would nonpathologic cyanosis normally be present in the newborn shortly after birth?
- A. Feet and hands
- B. Bridge of nose
- C. Circumoral area
- D. Mucous membranes
Correct answer: A
Rationale: Nonpathologic cyanosis in newborns shortly after birth is typically present in the feet and hands, known as acrocyanosis. This is a normal finding due to the immature peripheral circulation in newborns. Cyanosis of the bridge of the nose, circumoral area, and mucous membranes indicates generalized cyanosis, which suggests a potential underlying distress or major abnormality. Therefore, choice A is correct as it describes the expected location for nonpathologic cyanosis in newborns, while choices B, C, and D represent areas associated with abnormal cyanosis.
3. The nurse is discussing sexually transmitted infections (STIs) with a 17-year-old student. Which cognitive development theory should the teaching plan be based on?
- A. Sensorimotor reactions
- B. Limited cause and effect understanding
- C. Abstract thinking
- D. Concrete thinking
Correct answer: C
Rationale: The correct answer is C: 'Abstract thinking.' According to Piaget’s theory of cognitive development, adolescents, typically around the age of 12 and older, enter the formal operational stage where they can think abstractly and reason about hypothetical situations. When discussing complex topics like STIs with a 17-year-old student, it is essential to base the teaching plan on abstract thinking. Choice A, 'Sensorimotor reactions,' is incorrect as it pertains to the earliest stage in Piaget's theory (birth to 2 years old) focusing on sensory experiences and physical interactions. Choice B, 'Limited cause and effect understanding,' does not align with the cognitive abilities of a 17-year-old who is capable of more advanced thinking. Choice D, 'Concrete thinking,' is also incorrect as it refers to the stage before formal operations, where individuals think more concretely and struggle with abstract concepts.
4. What is the priority assessment for a nurse when caring for an infant suspected of having necrotizing enterocolitis (NEC)?
- A. Hold feedings.
- B. Check gastric residuals before feedings.
- C. Take rectal temperature.
- D. Closely monitor abdominal distention.
Correct answer: D
Rationale: The correct answer is D: Closely monitor abdominal distention. Monitoring the abdomen for signs of distention is crucial in the early detection of necrotizing enterocolitis (NEC). In NEC, the bowel wall is edematous and breaking down, leading to abdominal distention. Holding feedings is important in the management of NEC, as feedings may need to be stopped temporarily. Checking gastric residuals before feedings helps in assessing the infant's tolerance to feedings. Taking rectal temperatures is contraindicated in NEC as it can lead to the perforation of the bowel.
5. By which age should the nurse expect that an infant will be able to pull to a standing position?
- A. 5 to 6 months
- B. 7 to 8 months
- C. 11 to 12 months
- D. 14 to 15 months
Correct answer: C
Rationale: Pulling to a standing position typically occurs between 11 to 12 months, marking the progression towards walking.
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