Nursing Care of Children ATI

Nursing Care of Children ATI Related

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The nurse is assessing a 3-day-old breastfed newborn who weighed 3400 g (7 pounds, 8 oz) at birth. The infant's mother is now concerned because the infant weighs 3147 g (6 pounds, 15 oz). The most appropriate nursing intervention is what?

  • A. Recommend supplemental feedings of formula.
  • B. Explain that this weight loss is within normal limits.
  • C. Assess the child further to determine the cause of excessive weight loss.
  • D. Encourage the mother to express breast milk for bottle-feeding the infant.
Correct Answer: B

Rationale: A neonate normally loses about 10% of the birth weight by age 3 to 4 days. The birth weight is usually regained by the 10th day of life. In this case, the weight loss from 3400 g to 3147 g is within the expected range. Therefore, the most appropriate action is to explain to the mother that this weight loss is within normal limits. Choice A is incorrect because supplemental feedings of formula are not indicated for this expected weight loss in a breastfed newborn. Choice C is incorrect as there is no evidence to suggest excessive weight loss at this point. Choice D is unnecessary at this stage and may not align with the current situation of normal weight loss post-birth.

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An infant requires surgery for repair of a cleft lip. An important priority of the preoperative nursing care is which?

  • A. Initiating discharge teaching
  • B. Performing baseline physical and behavioral assessment
  • C. Observing for allergic reactions to preoperative antibiotics
  • D. Determining whether this defect exists in other family members
Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

The mother of a 3-month-old breastfed infant asks about giving her baby water because it is summer and very warm. What should the nurse tell her?

  • A. Fluids in addition to breast milk are not needed.
  • B. Water should be given if the infant seems to nurse longer than usual.
  • C. Clear juices are better than water to promote adequate fluid intake.
  • D. Water once or twice a day will make up for losses resulting from environmental temperature.
Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

In the newborn, into what muscle is intramuscular vitamin K administered?

  • A. Deltoid
  • B. Dorsogluteal
  • C. Rectus femoris
  • D. Vastus lateralis
Correct Answer: D

Rationale: In newborns, intramuscular vitamin K is traditionally administered into the vastus lateralis muscle. This site is preferred due to its large muscle mass and accessibility. The dorsogluteal site is not recommended for newborns due to the risk of injury to the sciatic nerve. The deltoid site is also not recommended for newborns. The rectus femoris muscle is not commonly used for intramuscular injections in newborns.

In teaching parents about appropriate pacifier selection, the nurse should recommend which characteristic?

  • A. Easily grasped handle
  • B. Detachable shield for cleaning
  • C. Soft, pliable material
  • D. Ribbon or string to secure to clothing
Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

The nurse is caring for a child with sickle cell anemia with the following order: Morphine Sulfate 2 mg IV every 24 hours. Morphine Sulfate is available in 10 mg/1mL. How many mL should the nurse administer?

  • A. 0.2 mL
  • B. 0.5 mL
  • C. 1 mL
  • D. 2 mL
Correct Answer: A

Rationale: To administer 2 mg of Morphine Sulfate when the concentration is 10 mg/mL, the nurse should administer 0.2 mL (2 mg / 10 mg/mL = 0.2 mL). Choice B, 0.5 mL, is incorrect because it is the result of dividing 2 mg by 4 mg/mL instead of 10 mg/mL. Choice C, 1 mL, is incorrect as it would be the result of dividing 2 mg by 2 mg/mL. Choice D, 2 mL, is incorrect as it would be the result of dividing 2 mg by 1 mg/mL.

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