the nurse is assessing a childs capillary refill time this can be accomplished by doing what
Logo

Nursing Elites

ATI RN

ATI Nursing Care of Children

1. The nurse is assessing a child's capillary refill time. This can be accomplished by doing what?

Correct answer: D

Rationale: Capillary refill time is assessed by applying pressure to the nail bed and observing how quickly the color returns, indicating peripheral circulation status.

2. An adolescent patient wants to make decisions about treatment options, along with his parents. Which moral value is the nurse displaying when supporting the adolescent to make decisions?

Correct answer: B

Rationale: Supporting an adolescent in making decisions about their care reflects the moral value of autonomy, emphasizing the importance of respecting the patient's right to make informed choices.

3. What findings would the nurse consider normal in assessing the anterior fontanel of a neonate?

Correct answer: D

Rationale: The correct answer is D: Pulsating anterior fontanel. The fontanel should feel flat, firm, and well demarcated. Pulsations are frequently visible at the anterior fontanel, which is a normal finding in a neonate. A closed anterior fontanel, as mentioned, is a potential sign of a major abnormality. A sunken or bulging fontanel (when the infant is quiet) may be indicative of distress or a major abnormality. Therefore, options A, B, and C are considered abnormal findings when assessing the anterior fontanel of a neonate.

4. What interventions would the nurse implement to maintain the skin integrity of a preterm infant born at 30 weeks?

Correct answer: B

Rationale: To maintain the skin integrity of a preterm infant born at 30 weeks, the nurse should bathe the infant with sterile water no more than two or three times per week. The eyes, oral and diaper areas, and pressure points should be cleansed daily. It is essential to avoid using alkaline-based soaps as they might destroy the 'acid mantle' of the skin. Additionally, cleansing with mild solutions and rinsing thoroughly with plain water is recommended to prevent skin irritation and maintain skin integrity. Therefore, options A, C, and D are incorrect as they do not align with the best practices for preterm infant skin care.

5. The parent asks when the soft area in the infant's head will go away. What is the best response by the nurse?

Correct answer: A

Rationale: The best response by the nurse is A, as the anterior fontanel typically closes between 12-18 months of age, allowing for brain growth during infancy. Choice B is incorrect because it does not provide a specific timeframe for the closure of the fontanel. Choice C is incorrect as it suggests a later closure timeframe than usual. Choice D is incorrect as it states that the soft spots should have closed already, which is inaccurate for a 6-month-old infant.

Similar Questions

Physiologically, the child compensates for fluid volume losses by which mechanism?
In which type of cancer are the urinary excretion of the breakdown products of catecholamines, especially vanillylmandelic acid (VMA) and homovanillic acid (HVA), detected?
The nurse is performing an oral examination on a preschool child. Which strategies should the nurse use to encourage the child to open the mouth for the examination? (Select all that apply.)
Which immunization should the nurse include in a teaching session for parents of toddler-age clients to decrease the risk for epiglottitis?
What amount of fluid loss occurs with moderate dehydration?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses