which assessment finding would necessitate action by the nurse for a 10 month old child who is 4 hours postoperative for the placement of a urethral s

ATI RN

RN Pediatric Nursing 2023 ATI

1. Which assessment finding would necessitate action by the nurse for a 10-month-old child who is 4 hours postoperative for the placement of a urethral stent?

A. Bloody urine
B. One void since returning from surgery
C. Bladder spasms responding to pharmacologic intervention
D. Double diapering from the previous shift

Correct answer: B

Rationale: In a postoperative scenario after the placement of a urethral stent, monitoring the child's voiding frequency is crucial. Having only one void since returning from surgery could indicate potential issues like urinary retention, which necessitates prompt nursing intervention to prevent complications.

2. A nurse is teaching a group of parents about preventing childhood obesity. Which of the following instructions should the nurse include?

A. Serve your child 1 to 2 cups of fruit juice daily
B. Feed your child whole milk until 2 years of age
C. Eat at least one fruit or vegetable with each meal
D. Limit your child's TV watching to 1 to 2 hr per day

Correct answer: D

Rationale: The nurse should instruct parents to limit their child’s TV watching to 1 to 2 hours per day to prevent childhood obesity.

3. What does a Z-score of -3.00 indicate?

A. The child's score indicates he is ahead of his peers and performing well
B. The child's score places him within normal limits on this test item
C. The test is inconclusive
D. The child's score falls below the majority of his peers on this test

Correct answer: D

Rationale: A Z-score of -3.00 indicates that the child's performance is significantly below the average of their peers. It represents an extreme low score, indicating a substantial deviation from the mean performance of the group.

4. Why is the specific gravity for infants lower than for older children?

A. Infants have a greater body surface area.
B. Infants have a higher basal metabolic rate.
C. Infants have a greater percentage of body weight that is water.
D. Infants' kidneys are less able to concentrate urine.

Correct answer: D

Rationale: The correct answer is D because infants' kidneys are less developed compared to older children, making them less efficient at concentrating urine. This results in a lower specific gravity in infants. The other choices do not directly explain why the specific gravity is lower in infants.

5. A patient is 1 hour postoperative following an open reduction internal fixation of the left tibia. Which of the following actions should the nurse take?

A. Assess neurovascular status of the extremities every 4 hours
B. Monitor the patient's pain level every 8 hours
C. Assist the patient to the bathroom every 2 hours
D. Keep the patient's left leg elevated on two pillows

Correct answer: A

Rationale: The correct action for the nurse to take 1 hour postoperative following an open reduction internal fixation of the left tibia is to assess neurovascular status of the extremities every 4 hours. This frequent assessment is crucial to monitor for any signs of complications such as impaired circulation or nerve damage. Monitoring every 4 hours allows for early detection of any issues, enabling timely intervention and prevention of potential complications. Monitoring the patient's pain level every 8 hours (choice B) is not as immediate or essential for postoperative care. Assisting the patient to the bathroom every 2 hours (choice C) may not be necessary if the patient is not ambulatory yet. Keeping the patient's left leg elevated on two pillows (choice D) can be beneficial but is not the priority in the immediate postoperative period compared to assessing neurovascular status.