which actions by the nurse demonstrate clinical reasoning select all that apply
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Nursing Elites

ATI RN

Nursing Care of Children Final ATI

1. Which actions by the nurse demonstrate clinical reasoning? (Select all that apply.)

Correct answer: A

Rationale: Clinical reasoning involves deliberate and thoughtful decision-making, considering alternatives, and using both formal and informal data gathering methods to provide optimum care.

2. The parents of a child with sickle cell anemia ask why their child did not have a sickle cell crisis until he was approximately 6 months old. How should the nurse respond?

Correct answer: C

Rationale: The correct answer is C. Fetal hemoglobin (HbF) is present in high levels during early infancy, inhibiting sickling unlike adult hemoglobin (HbS). As the levels of HbF decrease and HbS increases, the risk of sickling and crises becomes more pronounced, typically after 6 months of age. Choice A is incorrect because it assumes the crisis went unnoticed, which is not supported by medical knowledge. Choice B is incorrect as it questions the child's diagnosis rather than explaining the phenomenon of delayed crises. Choice D is incorrect as it does not provide the parents with the necessary information regarding their query.

3. What interventions would the nurse implement to maintain the skin integrity of a preterm infant born at 30 weeks?

Correct answer: B

Rationale: To maintain the skin integrity of a preterm infant born at 30 weeks, the nurse should bathe the infant with sterile water no more than two or three times per week. The eyes, oral and diaper areas, and pressure points should be cleansed daily. It is essential to avoid using alkaline-based soaps as they might destroy the 'acid mantle' of the skin. Additionally, cleansing with mild solutions and rinsing thoroughly with plain water is recommended to prevent skin irritation and maintain skin integrity. Therefore, options A, C, and D are incorrect as they do not align with the best practices for preterm infant skin care.

4. A mother delivers an infant at 30 weeks gestation and asks if formula is better than breast milk since the baby is premature. What should the nurse respond?

Correct answer: A

Rationale: Human milk is preferred, even for preterm infants, because it contains essential nutrients and antibodies that are particularly beneficial for their growth and development. Choice B is incorrect because human milk is rich in essential nutrients necessary for preterm infants. Choice C is incorrect as commercial infant formulas do not provide the same benefits as human milk. Choice D is incorrect as specialized formulas are available to meet the unique nutritional needs of preterm infants, but human milk remains the optimal choice.

5. The nurse is describing clinical reasoning to a group of nursing students. Which is most descriptive of clinical reasoning?

Correct answer: A

Rationale: Clinical reasoning is purposeful and goal-directed, involving the use of critical thinking and decision-making skills to provide effective patient care.

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