what is the priority assessment for a nurse when caring for an infant suspected of having necrotizing enterocolitis nec
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ATI Nursing Care of Children

1. What is the priority assessment for a nurse when caring for an infant suspected of having necrotizing enterocolitis (NEC)?

Correct answer: D

Rationale: The correct answer is D: Closely monitor abdominal distention. Monitoring the abdomen for signs of distention is crucial in the early detection of necrotizing enterocolitis (NEC). In NEC, the bowel wall is edematous and breaking down, leading to abdominal distention. Holding feedings is important in the management of NEC, as feedings may need to be stopped temporarily. Checking gastric residuals before feedings helps in assessing the infant's tolerance to feedings. Taking rectal temperatures is contraindicated in NEC as it can lead to the perforation of the bowel.

2. Superficial palpation of the abdomen is often perceived by the child as tickling. Which measure by the nurse is most likely to minimize this sensation and promote relaxation?

Correct answer: D

Rationale: Allowing the child to place their hand over the nurse's hand helps reduce the tickling sensation and increases the child's comfort during the examination.

3. One of the major differences in clinical presentation between Crohn disease (CD) and ulcerative colitis (UC) is that UC is more likely to cause which clinical manifestation?

Correct answer: B

Rationale: Rectal bleeding is more commonly associated with ulcerative colitis (UC) than with Crohn disease (CD). While both conditions can cause abdominal pain and growth issues, bleeding is a hallmark of UC due to its superficial mucosal inflammation. Perianal lesions are more characteristic of CD, and growth retardation is typically not a direct clinical manifestation of either CD or UC.

4. As the primary caregiver for a 5-month-old baby, according to Maslow’s hierarchy of basic needs, which intervention takes the highest priority?

Correct answer: A

Rationale: The correct answer is A: Feeding every four hours. According to Maslow’s hierarchy of needs, physiological needs, such as food, water, and warmth, take the highest priority. Ensuring that the baby is fed regularly is crucial for survival and overall health. Choice B, protection from harm, relates more to safety needs which come after physiological needs. Choice C, providing stimulation, is associated with higher-level needs like belongingness and esteem. Choice D, providing love, corresponds to esteem and self-actualization needs, which are higher in the hierarchy than physiological needs.

5. What is the leading cause of morbidity and mortality in children with cystic fibrosis?

Correct answer: A

Rationale: Respiratory infections are the leading cause of morbidity and mortality in children with cystic fibrosis. Cystic fibrosis primarily affects the respiratory system, leading to thick mucus buildup in the lungs, which predisposes these children to recurrent respiratory infections. Malnutrition and diabetes are common comorbidities in cystic fibrosis but are not the leading causes of morbidity and mortality in affected children. Liver disease can occur in cystic fibrosis but is less common than respiratory complications.

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