ATI RN
ATI Nursing Care of Children 2019 B
1. An infant is born with a gastroschisis. Care preoperatively should include which priority intervention?
- A. Prone position
- B. Sterile water feedings
- C. Monitoring serum laboratory electrolytes
- D. Covering the defect with a sterile bowel bag
Correct answer: D
Rationale: The correct priority intervention for an infant with gastroschisis is to cover the exposed abdominal contents with a sterile bowel bag. This action helps protect the intestines from injury, contamination, and dehydration before surgical repair. Choice A, placing the infant in the prone position, is not appropriate as it does not address the immediate need to protect the exposed intestines. Choice B, sterile water feedings, and Choice C, monitoring serum laboratory electrolytes, are not the priority interventions for this condition. Sterile water feedings may not provide the necessary protection for the exposed intestines, and monitoring electrolytes, while important, is secondary to the immediate need for protection and hydration of the exposed abdominal contents.
2. What is typically the first sign of puberty in females?
- A. Breast development
- B. Menarche
- C. Pubic hair growth
- D. Axillary hair growth
Correct answer: A
Rationale: The correct answer is A: Breast development (thelarche) is usually the first sign of puberty in females, typically beginning between ages 8 and 13. This marks the start of puberty, followed by pubic hair growth, a growth spurt, and eventually menarche (the onset of menstruation). Pubic hair growth and axillary hair growth usually follow breast development in the sequence of pubertal changes. Therefore, the first noticeable change indicating the onset of puberty in females is the development of breast buds.
3. 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.
4. A girl, age 5 1/2 years, has been sent to the school nurse for urinary incontinence three times in the past 2 days. The nurse should recommend to her parent that the first action is to have the child evaluated for what condition?
- A. School phobia
- B. Glomerulonephritis
- C. Urinary tract infection (UTI)
- D. Attention deficit hyperactivity disorder (ADHD)
Correct answer: C
Rationale: Urinary tract infections are a common cause of sudden onset urinary incontinence in children. While school phobia and ADHD can cause behavioral changes, a medical condition like a UTI should be ruled out first.
5. What play activities should the nurse implement to encourage fluid intake for a child? (Select all that apply.)
- A. Have a tea party.
- B. Use a crazy straw.
- C. Cut gelatin into fun shapes.
- D. All of the above
Correct answer: D
Rationale: Encouraging fluid intake can be fun and engaging through activities like having a tea party, using a crazy
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