the nurse is preparing to perform a physical assessment on a 10 year old girl the nurse gives her the option of her mother staying in the room or leav
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Nursing Elites

ATI RN

ATI Nursing Care of Children

1. The nurse is preparing to perform a physical assessment on a 10-year-old girl. The nurse gives her the option of her mother staying in the room or leaving. This action should be considered which?

Correct answer: A

Rationale: It is appropriate to give a 10-year-old the choice of having a parent present or not during an exam, respecting the child's growing need for privacy.

2. What laboratory finding should the nurse expect in a child with an excess of water?

Correct answer: A

Rationale: Water excess typically leads to hemodilution, resulting in a decreased hematocrit. High serum osmolality and specific gravity would indicate dehydration, while elevated BUN could suggest renal impairment or dehydration, not fluid overload.

3. During the 2-month well-child checkup, the nurse expects the infant to respond to sound in which manner?

Correct answer: B

Rationale: At 2 months, infants typically react to loud noises with the Moro reflex, a startle response that is normal at this stage of development.

4. The nurse has completed an education program on normal communication abilities in the preschool-age child. Which statement by a participant indicates a need for further education?

Correct answer: C

Rationale: The correct answer is C. By age 5, children should be able to state their name and address. If a child cannot do this, it may indicate a developmental delay that requires further assessment. Choices A, B, and D do not indicate a need for further education as they reflect typical developmental milestones for preschool-age children, such as gradually improving counting skills, asking many questions, and improving speech clarity over time.

5. The nurse is performing an assessment on a 12-month-old infant. Which fine or gross motor developmental skill demonstrates the proximodistal acquisition of skills?

Correct answer: C

Rationale: The development of a pincer grasp reflects fine motor skills, which develop in a proximodistal pattern (from the center of the body outward).

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