ATI RN
RN Nursing Care of Children Online Practice 2019 A
1. While making rounds, the nurse observes the following client behaviors. Which child should the nurse further evaluate for postoperative pain?
- A. The 6-month-old in deep sleep
- B. The 2-year-old who is cooperative when the nurse takes vital signs
- C. The 4-year-old who is actively watching cartoons
- D. The 14-month-old who is screaming and thrashing his arms and legs
Correct answer: D
Rationale: The correct answer is D because screaming and thrashing his arms and legs are indicative behaviors of discomfort or pain in young children. The child's actions suggest a higher likelihood of experiencing postoperative pain and necessitate further evaluation. Choices A, B, and C do not exhibit overt signs of distress or discomfort associated with pain, making them less likely candidates for postoperative pain assessment.
2. The nurse is teaching parents about expected language development for their 6-month-old infant. The nurse recognizes the parents understand the teaching if they make which statement?
- A. Our baby should comprehend the word no.
- B. Our baby knows the meaning of saying mama.
- C. Our baby should be able to say three to five words.
- D. Our baby should begin to combine syllables, such as dada.
Correct answer: D
Rationale: At 6 months, infants typically begin to combine syllables like "dada" or "mama," but they do not yet understand the meaning of these words.
3. What is the primary symptom of congenital diaphragmatic hernia in a newborn?
- A. Cyanosis
- B. Bradycardia
- C. Absent breath sounds
- D. Tachypnea
Correct answer: C
Rationale: Absent breath sounds on the affected side are a primary symptom of congenital diaphragmatic hernia. Cyanosis, bradycardia, and tachypnea may also be present but are not the primary symptom. Cyanosis is a bluish discoloration of the skin due to poor oxygenation, bradycardia is a slower than normal heart rate, and tachypnea is rapid breathing.
4. At which age do most infants begin to fear strangers?
- A. 2 months
- B. 4 months
- C. 6 months
- D. 12 months
Correct answer: C
Rationale: Fear of strangers typically begins around 6 months as infants start recognizing familiar and unfamiliar faces, which is part of their social development.
5. 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?
- A. Your child probably had a crisis, and you were unaware of the symptoms.
- B. Are you sure your child has sickle cell anemia and not sickle cell trait?
- C. Affected children can be asymptomatic in early infancy because of high levels of fetal hemoglobin that inhibit sickling.
- D. Have you asked your doctor about this yet?
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.