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

ATI RN

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. When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet is which?

Correct answer: C

Rationale: A diet rich in vegetables, legumes, and starches can provide sufficient amino acids, particularly when complemented with varied food sources to ensure a balanced intake of essential nutrients.

3. During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is which?

Correct answer: A

Rationale: A brilliant, uniform red reflex in both eyes is a normal finding, indicating that the retina is healthy and there are no significant obstructions in the visual pathway.

4. Kimberly is having a checkup before starting kindergarten. The nurse asks her to do the “finger-to-nose test.” What is the purpose of this test?

Correct answer: B

Rationale: The finger-to-nose test assesses cerebellar function, which is responsible for balance and coordination. The test evaluates how well the cerebellum controls motor functions and coordination. Choice A, deep tendon reflexes, is incorrect because this test does not assess reflexes but rather cerebellar function. Choice C, sensory discrimination, is incorrect as this test focuses on motor function rather than sensory abilities. Choice D, ability to follow directions, is incorrect since the test primarily assesses motor coordination and not cognitive skills related to following instructions.

5. What information should be given to the parents of a 12-month-old child regarding appropriate play activities for this age?

Correct answer: A

Rationale: Large push-pull toys are suitable for a 12-month-old as they encourage gross motor skills and physical activity, which are crucial for their development at this age.

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