ATI RN
Nursing Care of Children Final ATI
1. Why does the nurse have a 2-year-old boy sit in a “tailor” position while palpating for the presence of the testes?
- A. It prevents the cremasteric reflex
- B. Undescended testes can be palpated
- C. The child has an inguinal hernia
- D. The child does not yet have a need for privacy
Correct answer: A
Rationale: The tailor position stretches the muscle responsible for the cremasteric reflex, preventing it from contracting and pulling the testes into the pelvic cavity. This position helps accurately palpate the testes. Choice B is incorrect because the position does not facilitate the palpation of undescended testes specifically. Choice C is incorrect as it does not relate to the rationale behind the tailor position. Choice D is incorrect as the reason for using the tailor position is not related to the child's need for privacy.
2. 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.
3. A child is admitted with suspected pyloric stenosis. Which of the following should be included in the plan of care?
- A. Monitor for signs of metabolic acidosis
- B. Observe for projectile vomiting
- C. Provide large, infrequent feedings to allow for rest
- D. Place the infant in a supine position after feeding
Correct answer: B
Rationale: The correct answer is B: 'Observe for projectile vomiting.' Projectile vomiting is a classic sign of pyloric stenosis, caused by obstruction at the pylorus. Choice A is incorrect as metabolic alkalosis, not acidosis, often occurs due to the loss of hydrochloric acid from persistent vomiting. Choice C is incorrect as frequent, small feedings are preferred to prevent overloading the stomach. Choice D is incorrect as placing the infant in an upright position after feeding can help reduce reflux.
4. A new mom is ready to introduce solid foods to her infant. Which food would you recommend starting with?
- A. Meat
- B. Rice cereal
- C. Fruits
- D. Vegetables
Correct answer: B
Rationale: The correct answer is B: Rice cereal. Rice cereal is typically the first solid food introduced to infants because it is easy to digest and unlikely to cause an allergic reaction. Starting with rice cereal helps assess the baby's readiness for solid foods and reduces the risk of allergic responses. Choice A (Meat) is not recommended as the initial solid food due to its higher allergenic potential. Choices C (Fruits) and D (Vegetables) are also not usually recommended as the first solid food, as they may be more challenging for infants to digest compared to rice cereal.
5. Which best describes signs and symptoms as part of a nursing diagnosis?
- A. Description of potential risk factors
- B. Identification of actual health problems
- C. Human response to state of illness or health
- D. Cues and clusters derived from patient assessment
Correct answer: D
Rationale: Signs and symptoms are cues and clusters derived from patient assessments that are used to form a nursing diagnosis, guiding the development of a care plan.