an infant is diagnosed with a tracheoesophageal fistula which assessment finding should the nurse expect

ATI RN

Nursing Care of Children ATI

1. An infant is diagnosed with a tracheoesophageal fistula. Which assessment finding should the nurse expect?

A. Jaundice
B. Hyperactive bowel sounds
C. Absence of sucking, vomiting
D. Coughing, with excessive secretion

Correct answer: D

Rationale: Coughing with excessive secretion is a common sign of tracheoesophageal fistula. In this condition, the connection between the trachea and esophagus allows saliva and food to enter the airways, leading to coughing and excessive secretions. Choice A, jaundice, is not typically associated with tracheoesophageal fistula. Hyperactive bowel sounds (Choice B) are more likely seen in conditions like gastroenteritis. Absence of sucking and vomiting (Choice C) is not a typical finding related to tracheoesophageal fistula.

2. A child with acute gastrointestinal bleeding is admitted to the hospital. The nurse observes which sign or symptom as an early manifestation of shock?

A. Restlessness
B. Rapid capillary refill
C. Increased temperature
D. Increased blood pressure

Correct answer: A

Rationale: Restlessness is an early sign of shock due to decreased perfusion and oxygenation to the brain. This symptom requires immediate attention to prevent the progression to more severe stages of shock. Rapid capillary refill (Choice B) is not typically an early sign of shock but rather a sign of adequate perfusion. Increased temperature (Choice C) may occur in later stages of shock due to the body's response to stress. Increased blood pressure (Choice D) is not an early sign of shock; in fact, blood pressure tends to decrease in shock as a compensatory mechanism.

3. The nurse is reviewing the Healthy People 2020 leading health indicators for a child health promotion program. Which are included in the leading health indicators? (Select all that apply.)

A. Decrease tobacco use
B. Improve immunization rates
C. All are applicable
D. Increase access to health care

Correct answer: C

Rationale: Healthy People 2020 focuses on decreasing tobacco use, improving immunization rates, and increasing access to healthcare among its leading health indicators.

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

A. Pupils react to light
B. Tear glands function
C. Blink reflex is absent
D. Ciliary muscles are mature

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.

5. What is often the initial sign of acute rheumatic fever in children?

A. Polyarthritis
B. Carditis
C. Erythema marginatum
D. Sydenham chorea

Correct answer: A

Rationale: Polyarthritis is indeed frequently the initial sign of acute rheumatic fever in children. It presents as joint pain, swelling, and redness. Carditis (inflammation of the heart), Erythema marginatum (a skin rash), and Sydenham chorea (involuntary muscle movements) are typically seen in the later stages of acute rheumatic fever and not as the initial sign.