at a well child check up the nurse notes that an infant with a previous diagnosis of failure to thrive ftt is now steadily gaining weight the nurse sh

ATI RN

Nursing Care of Children ATI

1. At a well-child check-up, the nurse notes that an infant with a previous diagnosis of failure to thrive (FTT) is now steadily gaining weight. The nurse should recommend that fruit juice intake be limited to no more than how much?

A. 4 oz/day
B. 6 oz/day
C. 8 oz/day
D. 12 oz/day

Correct answer: A

Rationale: The American Academy of Pediatrics recommends limiting fruit juice intake to no more than 4 oz per day for infants, as excessive juice can contribute to poor nutrition and dental issues.

2. Which sign is indicative of developmental dysplasia of the hip in infants?

A. Ortolani sign
B. Romberg sign
C. Trendelenburg sign
D. Gower's sign

Correct answer: A

Rationale: The Ortolani sign is a specific maneuver used during physical examination to detect hip instability or dislocation in infants. A positive Ortolani sign, where the hip is felt to slip back into the socket, is indicative of developmental dysplasia of the hip, a condition that can lead to long-term disability if not treated early. Romberg sign is used to assess sensory ataxia, Trendelenburg sign indicates weakness of the hip abductor muscles, and Gower's sign is seen in children with proximal muscle weakness climbing up their own body from a supine position due to conditions like muscular dystrophy.

3. How is family systems theory best described?

A. The family is viewed as the sum of individual members
B. A change in one family member cannot create a change in other members
C. Individual family members are readily identified as the source of a problem
D. When the family system is disrupted, change can occur at any point in the system

Correct answer: D

Rationale: Family systems theory views the family as a whole, where changes in one member affect the entire system, and changes can occur at any point within the system.

4. When transitioning from intravenous to oral morphine, what would the nurse anticipate regarding the oral dose in comparison to the intravenous dose to achieve equianalgesia?

A. Same as the intravenous dose
B. Greater than the intravenous dose
C. One half of the intravenous dose
D. One fourth of the intravenous dose

Correct answer: B

Rationale: When switching from intravenous to oral morphine, a higher oral dose is required to achieve equianalgesia due to significant metabolism from the first-pass effect. Choosing the same oral dose as the intravenous dose would provide less pain relief. Opting for a dose greater than the intravenous dose is necessary to achieve the same analgesic effect. Therefore, options A, C, and D are incorrect.

5. What laboratory finding should the nurse expect in a child with an excess of water?

A. Decreased hematocrit
B. High serum osmolality
C. High urine specific gravity
D. Increased blood urea nitrogen (BUN)

Correct answer: A

Rationale: Water excess typically leads to hemodilution, resulting in a decreased hematocrit. High serum osmolality and specific gravity would indicate dehydration, while elevated BUN could suggest renal impairment or dehydration, not fluid overload.