the nurse is assessing a 3 year old african american child whose height and weight are at the 20th percentile on the growth chart what should the nurs
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Nursing Elites

ATI RN

RN Nursing Care of Children Online Practice 2019 A

1. The nurse is assessing a 3-year-old African American child whose height and weight are at the 20th percentile on the growth chart. What should the nurse recognize?

Correct answer: B

Rationale: The NCHS growth charts serve as reference guides for all racial or ethnic groups, including African American children. The 20th percentile for height and weight does not indicate nutritional failure but provides a reference point for ongoing assessment. Choice A is incorrect because being at the 20th percentile does not automatically imply the need for nutritional intervention. Choice C is incorrect as there is no correction factor specifically used for nonwhite ethnic groups in this context. Choice D is incorrect as a single measurement at the 20th percentile can provide valuable information for assessment.

2. Which of the following is a hallmark sign of intussusception in children?

Correct answer: B

Rationale: "Currant jelly" stools, consisting of mucus and blood, are characteristic of intussusception in children. It occurs due to the telescoping of a segment of the intestine into an adjacent segment, leading to obstruction and subsequent mucosal ischemia, causing the passage of bloody mucus in the stool. Bilious vomiting can be seen in other conditions like bowel obstruction, abdominal distention can be present but is not as specific, and constipation is less likely in the presentation of intussusception.

3. At what age is binocularity, the ability to fixate on one visual field with both eyes simultaneously, typically achieved?

Correct answer: B

Rationale: Binocularity, the ability to fixate on one visual field with both eyes simultaneously, is typically achieved by the age of 3 to 4 months. Achieving binocularity at 1 month is too early for most infants as their visual system is still developing. Similarly, 6 to 8 months and 12 months are beyond the normal age range for achieving binocularity, and delayed achievement could indicate potential issues like strabismus, which may lead to visual impairment if not addressed.

4. Which drug is usually the best choice for patient-controlled analgesia (PCA) for a child in the immediate postoperative period?

Correct answer: B

Rationale: Morphine is the drug of choice for PCA in children because of its efficacy, safety profile, and rapid onset of action for pain management.

5. The Asian parent of a child being seen in the clinic avoids eye contact with the nurse. What is the best explanation for this considering cultural differences?

Correct answer: B

Rationale: In many Asian cultures, avoiding eye contact is a sign of respect, especially towards authority figures such as healthcare providers.

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