ATI RN
ATI Nursing Care of Children 2019 B
1. What is a classic sign of congenital hypothyroidism in newborns?
- A. Jaundice
- B. Hypothermia
- C. Prolonged jaundice
- D. Excessive crying
Correct answer: C
Rationale: Prolonged jaundice is a classic sign of congenital hypothyroidism in newborns. In congenital hypothyroidism, the thyroid gland does not produce enough thyroid hormones, leading to symptoms like jaundice, poor feeding, constipation, and lethargy. While jaundice itself is a common condition in newborns, the term 'prolonged jaundice' specifically points towards the underlying thyroid issue. Hypothermia and excessive crying are not typically associated with congenital hypothyroidism.
2. What tool would be most useful to assess maternal and newborn attachment behaviors?
- A. Apgar
- B. Ballard scale
- C. NCAST (Nursing Child Assessment Satellite Training) Feeding Scale
- D. Brazelton Neonatal Behavioral Assessment Scale
Correct answer: C
Rationale: The NCAST Feeding Scale is the most suitable tool to evaluate maternal and newborn attachment behaviors during feedings. It focuses on observing the interaction between the parent and infant, providing insights into their bonding. The Apgar score is used to assess a neonate's immediate transition to life outside the womb, not specifically maternal and newborn attachment behaviors. The Ballard scale is used to estimate gestational age, not to assess attachment behaviors. The Brazelton Neonatal Behavioral Assessment Scale is designed to evaluate a newborn's responses to various stimuli, not specifically maternal and newborn attachment behaviors.
3. One of the most critical needs of the infant is control of body temperature. The nurse caring for a newborn warms all equipment that comes in direct contact with the newborn to help prevent which type of heat loss?
- A. Convection
- B. Evaporation
- C. Conduction
- D. Radiation
Correct answer: C
Rationale: The correct answer is Conduction (choice C). Conduction heat loss occurs when the newborn’s skin comes into direct contact with a cooler surface, so warming equipment helps prevent this. Choice A, Convection, is the transfer of heat through air or water currents, not direct contact. Choice B, Evaporation, is the loss of heat through moisture on the skin evaporating, not direct contact. Choice D, Radiation, is the transfer of heat in the form of waves or particles, not direct contact.
4. A new parent, when asked by a nurse, explains that the 4-month-old infant has been nursing regularly every 3 to 4 hours and seems satisfied. However, the parent recently introduced solid food in the form of unbuttered popcorn to the infant as a supplement. What should be the primary nursing concern in this situation?
- A. Imbalanced nutrition, more than body requirements, related to introduction of a high-calorie food
- B. Risk for aspiration related to feeding the infant an inappropriate food
- C. Imbalanced nutrition, less than body requirements, related to introduction of a low-nutritive food
- D. Readiness for enhanced nutrition, related to the age of the infant
Correct answer: B
Rationale: The primary nursing concern in this situation is the risk for aspiration. Popcorn is a choking hazard for infants, as their airway is not fully developed to handle solid foods like popcorn. Choices A, C, and D are incorrect because the main focus should be on the immediate risk of aspiration due to the inappropriate solid food given to the infant, rather than on nutritional imbalances or readiness for enhanced nutrition.
5. 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?
- A. Appropriate because of the child's age
- B. Appropriate, but the mother may be uncomfortable
- C. Inappropriate because of the child's age
- D. Inappropriate because the child is the same sex as the mother
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.
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