what is the earliest age at which a satisfactory radial pulse can be taken in children
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Nursing Elites

ATI RN

ATI Nursing Care of Children

1. What is the earliest age at which a satisfactory radial pulse can be taken in children?

Correct answer: C

Rationale: A satisfactory radial pulse can typically be taken starting at around 3 years of age, as younger children often have pulses that are too fast and irregular for accurate measurement.

2. A parent brings their 2-year-old son in for a well visit. The nurse assesses his growth since the last appointment. Which finding should concern the nurse?

Correct answer: D

Rationale: The correct answer is D. A total weight gain of 15 lb in one year for a 2-year-old is excessive and may indicate an underlying issue such as a metabolic disorder or overfeeding. This rapid weight gain can put the child at risk for health problems. Choices A, B, and C are not typically concerning findings in a 2-year-old. A prominent abdomen can be normal at this age due to a toddler's slightly protruding belly, a forward curve of the spine at the sacral area is a typical finding in young children, and an increase in height of 5 inches in a year is within the expected range of growth for a 2-year-old.

3. A 12-year-old girl has recently begun menstruating and is well into puberty. The child is visiting the health care provider today for a routine physical examination. Which finding should cause concern in the nurse?

Correct answer: C

Rationale: Vulvar irritation may indicate an infection or other issues and should be further evaluated. In a pubescent girl, breasts of slightly different sizes and irregular periods are common variations of normal development. Supernumerary nipple, an extra nipple, is a benign condition that is not typically concerning during puberty.

4. What signs or symptoms are most commonly associated with the prodromal phase of acute viral hepatitis?

Correct answer: B

Rationale: The correct answer is B: Anorexia and malaise. The prodromal phase of acute viral hepatitis is characterized by nonspecific symptoms such as anorexia (loss of appetite) and malaise (general feeling of discomfort). These symptoms typically precede the more specific signs of jaundice, dark urine, and pale stools that manifest in the icteric phase. Choices A, C, and D are incorrect because bruising and lethargy, fatigability and jaundice, and dark urine and pale stools are typically seen in later stages of acute viral hepatitis, not in the prodromal phase.

5. What findings would the nurse consider normal in assessing the anterior fontanel of a neonate?

Correct answer: D

Rationale: The correct answer is D: Pulsating anterior fontanel. The fontanel should feel flat, firm, and well demarcated. Pulsations are frequently visible at the anterior fontanel, which is a normal finding in a neonate. A closed anterior fontanel, as mentioned, is a potential sign of a major abnormality. A sunken or bulging fontanel (when the infant is quiet) may be indicative of distress or a major abnormality. Therefore, options A, B, and C are considered abnormal findings when assessing the anterior fontanel of a neonate.

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