the nurse is providing anticipatory guidance to parents of a 4 month old infant on preventing an aspiration injury what should the nurse include in th
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Nursing Care of Children ATI

1. The nurse is providing anticipatory guidance to parents of a 4-month-old infant on preventing an aspiration injury. What should the nurse include in the teaching?

Correct answer: A

Rationale: Baby powder can be inhaled by the infant and cause respiratory distress. Toys should be inspected to prevent choking hazards. Allowing an infant to take a bottle to bed can increase the risk of aspiration, and hard foods like teething biscuits should be given with caution.

2. The nurse is teaching a nursing student about standard precautions. Which statement made by the student indicates a need for further teaching?

Correct answer: D

Rationale: Standard precautions are necessary when dealing with blood, body fluids, and potentially infectious materials. They are not required for routine administration of oral medications unless there is a potential exposure risk.

3. The nurse is planning care for a hospitalized preschool-aged child. Which should the nurse plan to ensure atraumatic care?

Correct answer: C

Rationale: Allowing the child to make choices, such as selecting the type of juice, helps to maintain a sense of control and reduce anxiety, ensuring atraumatic care.

4. The nurse is teaching parents of a child with gastroesophageal reflux (GER) disease about foods that can exacerbate acid reflux. What foods should be included in the teaching session?

Correct answer: B

Rationale: The correct answer is B: All of the above. Citrus, spicy foods, and peppermint are known to exacerbate GER symptoms by increasing acid production or relaxing the lower esophageal sphincter. Therefore, these foods should be avoided by a child with GER disease. Bananas, on the other hand, are generally safe and do not contribute to acid reflux. Choice B is correct because all the mentioned foods can worsen GER symptoms, while bananas are considered safe.

5. The nurse is assessing a 3-day-old breastfed newborn who weighed 3400 g (7 pounds, 8 oz) at birth. The infant’s mother is now concerned because the infant weighs 3147 g (6 pounds, 15 oz). The most appropriate nursing intervention is what?

Correct answer: B

Rationale: A neonate normally loses about 10% of the birth weight by age 3 to 4 days. The birth weight is usually regained by the 10th day of life. In this case, the weight loss from 3400 g to 3147 g is within the expected range. Therefore, the most appropriate action is to explain to the mother that this weight loss is within normal limits. Choice A is incorrect because supplemental feedings of formula are not indicated for this expected weight loss in a breastfed newborn. Choice C is incorrect as there is no evidence to suggest excessive weight loss at this point. Choice D is unnecessary at this stage and may not align with the current situation of normal weight loss post-birth.

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