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. The nurse is preparing a 9-year-old boy before obtaining a blood specimen by venipuncture. The child tells the nurse he does not want to lose his blood. What approach is best by the nurse?

Correct answer: C

Rationale: Discussing how the body continuously makes blood helps the child understand that losing a small amount is normal and not harmful. This educational approach also helps reduce anxiety by giving the child a sense of control over the situation.

3. The nurse is caring for a child with suspected ingestion of some type of poison. What action should the nurse take next after initiating cardiopulmonary resuscitation (CPR)?

Correct answer: D

Rationale: After ensuring the child's immediate survival needs are met with CPR, contacting poison control is critical to receive specific guidance on how to proceed with treatment. Other actions may be necessary depending on the situation but should follow contacting poison control.

4. An adolescent patient wants to make decisions about treatment options, along with his parents. Which moral value is the nurse displaying when supporting the adolescent to make decisions?

Correct answer: B

Rationale: Supporting an adolescent in making decisions about their care reflects the moral value of autonomy, emphasizing the importance of respecting the patient's right to make informed choices.

5. An important intervention for infants with developmental disabilities is to:

Correct answer: B

Rationale: The correct answer is B: Stress the importance of early infant stimulation and intervention programs. Early intervention programs are essential for infants with developmental disabilities as they can significantly impact the child's development and future outcomes. These programs provide necessary support and therapies to enhance the child's skills and abilities. Choice A is incorrect because it is crucial to provide hope and support to parents, emphasizing the potential for development and progress. Choice C is inappropriate and unethical as the first line of intervention. Institutionalization should only be considered in extreme cases where other options have been exhausted. Choice D is not the most crucial intervention at this stage. While reevaluation may be necessary, early intervention and support should be prioritized to maximize the child's developmental potential.

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