ATI Nursing Care of Children

Correct Answer: B

Rationale: Rectal temperatures provide the most accurate measurement of core body temperature and are therefore indicated when accuracy is essential.

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.

Correct Answer: C

Rationale: Significant head lag at 8 months is concerning and warrants further evaluation, as it may indicate developmental delays or neurological issues.

Correct Answer: A

Rationale: The correct response is A. Solid foods, especially iron-fortified cereals, are introduced to meet the infant's increased nutritional needs, including iron, which breast milk alone may not provide adequately. Choice B is incorrect because the extrusion reflex is related to the tongue-thrust reflex, not the nutritional needs of the infant. Choice C is incorrect as breastfeeding does not become painful when the infant gets more teeth, and it is not a reason for introducing solid foods. Choice D is incorrect as the infant's interest in trying new skills is not a primary reason for introducing solid foods at this age.

Correct Answer: A

Rationale: Immunizations are part of the patient's health history and are recorded under the history section to ensure the child is up-to-date with vaccinations.