what is the most appropriate nursing action for a child with epistaxis
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Nursing Elites

ATI RN

ATI Nursing Care of Children 2019 B

1. What is the most appropriate action for a child with epistaxis?

Correct answer: B

Rationale: The most appropriate action for a child with epistaxis is to pinch the nose and lean forward. This technique helps stop the bleeding and prevent aspiration of blood. By applying pressure to the bleeding vessels and allowing the blood to drain out of the nostrils instead of being swallowed, the risk of nausea and airway obstruction is reduced. Having the child lie flat (Choice A) may lead to blood flowing down the throat, causing potential choking. Applying a warm compress (Choice C) is not typically recommended for epistaxis as cold compresses are more effective. Encouraging deep breathing (Choice D) is not directly related to managing epistaxis.

2. How is masturbation in the pre-school child viewed?

Correct answer: C

Rationale: Masturbation in preschool children is a normal behavior as they explore their bodies. It is best viewed as a natural part of development. Parents are often advised to ignore it and provide distractions rather than making the child feel ashamed or embarrassed. Choice A is incorrect because it is a natural behavior and not considered abnormal in this context. Choice B is incorrect as it does not necessarily disrupt the family. Choice D is incorrect as the focus should be on the child's development and well-being, not on the parents' feelings of embarrassment.

3. What recommendation should the nurse make to prevent urinary tract infections (UTIs) in young girls?

Correct answer: C

Rationale: Proper perineal hygiene, including cleansing with water after voiding, is crucial in preventing UTIs in young girls. Avoiding public toilets and limiting baths are less effective than proper hygiene practices.

4. The nurse is discussing growth and development with a group of parents. What should the nurse say about developmental milestones?

Correct answer: B

Rationale: The correct answer is B: "Age-specific tasks that most children can do at a certain time." Developmental milestones are specific tasks or abilities that most children can achieve at a certain age range. Choices A, C, and D are incorrect because developmental milestones are not just about increase in body size, the direction of growth, or the age group of children. They are more focused on the expected tasks and skills children can accomplish at particular ages.

5. The parent asks when the soft area in the infant's head will go away. What is the best response by the nurse?

Correct answer: A

Rationale: The best response by the nurse is A, as the anterior fontanel typically closes between 12-18 months of age, allowing for brain growth during infancy. Choice B is incorrect because it does not provide a specific timeframe for the closure of the fontanel. Choice C is incorrect as it suggests a later closure timeframe than usual. Choice D is incorrect as it states that the soft spots should have closed already, which is inaccurate for a 6-month-old infant.

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