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. What is an approximate method of estimating output for a child who is not toilet trained?

Correct answer: B

Rationale: Weighing diapers is the most accurate way to estimate urine output in a child who is not toilet trained. This method provides a measurable and reliable estimate of fluid output.

3. A 3-year-old child was adopted immediately after birth. The parents have just asked the nurse how they should tell the child that she is adopted. Which guideline concerning adoption should the nurse use in planning a response?

Correct answer: D

Rationale: It is important to tell children about their adoption early, in an age-appropriate manner, as part of building trust and openness in the family relationship.

4. Melena, the passage of black, tarry stools, suggests bleeding from which source?

Correct answer: B

Rationale: Melena indicates bleeding from the upper GI tract. The black, tarry appearance of the stool results from the partial digestion of blood as it passes through the intestines, typically originating from sources like the stomach or duodenum. Lower GI bleeding usually presents as bright red blood in the stool, originating from sources like the colon or rectum. Choices A, C, and D are incorrect because melena specifically points to upper GI bleeding rather than issues in the perianal/rectal area, lower GI tract, or hemorrhoids/anal fissures.

5. Which nursing intervention should be included in the postoperative care of a child following a tonsillectomy?

Correct answer: D

Rationale: The correct answer is D: 'Avoid giving citrus juice.' Citrus juice can irritate the throat after a tonsillectomy, so it should be avoided. Choice A is incorrect because blowing the nose gently is not a recommended intervention following a tonsillectomy. Choice B is incorrect as mucus in emesis is not uncommon postoperatively and does not necessarily require physician notification. Choice C is incorrect as positioning the child supine immediately postoperatively can increase the risk of airway obstruction and should be avoided.

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