the nurse is performing an otoscopic examination on a child which are normal findings the nurse should expect select all that apply
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Nursing Elites

ATI RN

ATI Nursing Care of Children

1. The nurse is performing an otoscopic examination on a child. Which are normal findings the nurse should expect? (Select all that apply.)

Correct answer: A

Rationale: A well-defined light reflex, a small concave spot, and a grayish, nontransparent tympanic membrane are normal findings during an otoscopic examination in a child.

2. The nurse is caring for a 1-month-old infant diagnosed with Hirschsprung’s disease. Which treatment measure should be included in the plan of care?

Correct answer: B

Rationale: The correct answer is B: Surgical removal of the affected section of bowel. Hirschsprung's disease is a congenital condition where a portion of the large intestine lacks nerve cells, leading to difficulties in passing stool. The definitive treatment for this condition is the surgical removal of the affected section of the bowel. Barium enema (Choice A) may be used for diagnosis but is not a treatment. A high-fiber diet (Choice C) is not effective in managing Hirschsprung's disease. A permanent colostomy (Choice D) is not the initial treatment for this condition in infants.

3. A parent of an infant with gastroesophageal reflux asks how to decrease the number and total volume of emesis. What recommendation should the nurse include in teaching this parent?

Correct answer: C

Rationale: The correct recommendation for decreasing the number and total volume of emesis in an infant with gastroesophageal reflux is to thicken feedings and enlarge the nipple hole. Thicker feedings can reduce the frequency and volume of emesis by making the food less likely to be regurgitated. Enlarging the nipple hole helps ensure the thickened feedings can pass through. Surgical therapy (Choice A) is not the initial recommendation for managing gastroesophageal reflux in infants. Placing the infant in a prone position for sleep after feeding (Choice B) is not recommended due to the increased risk of sudden infant death syndrome (SIDS). Reducing the frequency of feeding by encouraging larger volumes of formula (Choice D) can exacerbate the reflux symptoms.

4. Evidence-based practice (EBP), a decision-making model, is best described as which?

Correct answer: D

Rationale: Evidence-based practice involves gathering and integrating all relevant evidence to guide clinical decision-making, ensuring that care is based on the best available research.

5. The caregiver asks why the 6-month-old infant needs to have solid foods when breast milk is such a good source of nutrition. What would be the best response by the nurse?

Correct answer: A

Rationale: The correct response is A. Solid foods, especially iron-fortified cereals, are introduced to meet the infant's increased nutritional needs, including iron, which breast milk alone may not provide adequately. Choice B is incorrect because the extrusion reflex is related to the tongue-thrust reflex, not the nutritional needs of the infant. Choice C is incorrect as breastfeeding does not become painful when the infant gets more teeth, and it is not a reason for introducing solid foods. Choice D is incorrect as the infant's interest in trying new skills is not a primary reason for introducing solid foods at this age.

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