the nurse needs to take the blood pressure of a small child of the cuffs available one is too large and one is too small the best nursing action is wh
Logo

Nursing Elites

ATI RN

ATI Nursing Care of Children

1. The nurse needs to take the blood pressure of a small child. Of the cuffs available, one is too large and one is too small. The best nursing action is which?

Correct answer: D

Rationale: It is essential to use the correct cuff size for accurate blood pressure readings; if the proper size is not available, it's best to wait until it can be obtained.

2. 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.

3. What is the appropriate method for measuring the temperature of a 2-day-old neonate?

Correct answer: C

Rationale: For a 2-day-old neonate, the most suitable method to measure temperature is the axillary method. This approach is considered safe and appropriate for neonates, minimizing the risk of injury. Tympanic temperature measurement may not be as accurate in neonates due to their small ear canals. Oral temperature measurement is not recommended for neonates as they may not be able to hold a thermometer properly in their mouths. Rectal temperature measurement is invasive and carries a higher risk of injury and should be avoided unless absolutely necessary.

4. A parent asks the nurse what would be the first indication that acute glomerulonephritis was improving. What would be the nurse's best response?

Correct answer: D

Rationale: Increased urine output is often the first sign that acute glomerulonephritis is improving, as it indicates a reduction in fluid retention and better kidney function. Stabilization of blood pressure and other symptoms typically follow.

5. The parents of an 8-month-old infant voice concern to the nurse that their infant is not developing motor skills as the infant should. What question would be appropriate for the nurse to ask in determining if their fears are warranted?

Correct answer: A

Rationale: The correct answer is A. By 8 months, an infant should be able to transfer objects between hands, which is an important motor skill milestone. This action shows coordination and developing fine motor skills. Choices B, C, and D involve more advanced motor skills that are typically not expected at 8 months of age. Drinking from a cup, holding a pencil to scribble, and engaging in purposeful play with toys are skills that develop later in infancy.

Similar Questions

The parents of a newborn with an umbilical hernia ask about treatment options. The nurse's response should be based on which knowledge?
Frequent urine tests for specific gravity are required on a 6-month-old infant. What method is the most appropriate way to collect small amounts of urine for these tests?
In children with Type 1 diabetes, what is a common early sign of hypoglycemia?
As the primary caregiver for a 5-month-old baby, according to Maslow’s hierarchy of basic needs, which intervention takes the highest priority?
What is an important priority in dealing with the child suspected of having Wilms tumor?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses