the nurse is describing clinical reasoning to a group of nursing students which is most descriptive of clinical reasoning
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Nursing Care of Children Final ATI

1. The nurse is describing clinical reasoning to a group of nursing students. Which is most descriptive of clinical reasoning?

Correct answer: A

Rationale: Clinical reasoning is purposeful and goal-directed, involving the use of critical thinking and decision-making skills to provide effective patient care.

2. Superficial palpation of the abdomen is often perceived by the child as tickling. Which measure by the nurse is most likely to minimize this sensation and promote relaxation?

Correct answer: D

Rationale: Allowing the child to place their hand over the nurse's hand helps reduce the tickling sensation and increases the child's comfort during the examination.

3. The nurse is preparing to admit a child to the hospital with a diagnosis of acute poststreptococcal glomerulonephritis. The nurse understands that the peak age at onset for this disease is what?

Correct answer: B

Rationale: The peak age for the onset of acute poststreptococcal glomerulonephritis is typically between 5 and 7 years old. This age group is most affected due to the higher incidence of streptococcal infections in school-aged children, which can lead to this renal complication.

4. The parent of a 1-month-old infant voices concern about the infant’s respirations. The parent states the respirations are rapid and irregular. Which information should the nurse provide?

Correct answer: B

Rationale: The correct answer is B. Irregular respirations with periodic pauses are normal in a 1-month-old infant. Choice A is incorrect because the normal respiratory rate for an infant at this age is higher than the range provided. Choice C is incorrect as irregular respirations are expected in infants. Choice D is not appropriate as irregular respirations with periodic pauses are a normal finding in young infants and do not necessarily indicate a concern that requires immediate notification of the healthcare provider.

5. What is the appropriate site to administer an intramuscular (IM) vaccine to a newborn?

Correct answer: B

Rationale: The correct site to administer an intramuscular (IM) vaccine to a newborn is the vastus lateralis muscle. For newborns, the vastus lateralis is preferred over the dorsogluteal site because the dorsogluteal site has been associated with low antibody seroconversion rates, indicating a reduced immune response. The vastus lateralis is also recommended for IM injections in newborns, while the deltoid muscle is preferred for older infants and children. The ventral gluteal muscle and the biceps muscle are not appropriate sites for IM injections. Therefore, choice B is the correct answer.

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