ATI Nursing Care of Children

Correct Answer: A

Rationale: Directly asking the adolescent if she is sexually active is the most straightforward and respectful approach, ensuring privacy and fostering trust.

Correct Answer: A

Rationale: Engaging the infant in a familiar game like peek-a-boo can help reduce fear and build rapport before starting the assessment.

Correct Answer: A

Rationale: Vesicular breath sounds are normally heard over most of the lung fields, except near the trachea and main bronchi, where bronchial or bronchovesicular sounds may be heard.

Correct Answer: C

Rationale: In extremely low-birth-weight (ELBW) infants, a thorough systemic physical assessment is crucial to detect subtle changes that may indicate an underlying problem. These infants are highly vulnerable and may show signs of stress through changes in feeding behavior, activity, color, oxygen saturation, or vital signs. Monitoring weight in ELBW infants primarily reflects genitourinary function rather than fluid retention. Difficulties in maternal-child attachment are important but are usually assessed during parental visits and are not the primary focus of a systemic physical assessment. Changes in the Apgar score are used immediately after birth to assess the transition to extrauterine life and are not as relevant in the following 24 hours to detect ongoing subtle issues.

Correct Answer: B

Rationale: The correct answer is B: 'Observe for projectile vomiting.' Projectile vomiting is a classic sign of pyloric stenosis, caused by obstruction at the pylorus. Choice A is incorrect as metabolic alkalosis, not acidosis, often occurs due to the loss of hydrochloric acid from persistent vomiting. Choice C is incorrect as frequent, small feedings are preferred to prevent overloading the stomach. Choice D is incorrect as placing the infant in an upright position after feeding can help reduce reflux.