A nurse is providing care to children on a general pediatric unit. Which of the following children should the nurse identify as a potential victim of abuse?

A child whose parents answer questions for the child.

A child who has frequent visitors

A child who uses the call light frequently

A child who has a BMI indicating obesity

Answer and Explanation

The Correct Answer is A

A. A child whose parents answer questions for the child. This behavior may indicate that the child's parents are controlling or dominating, possibly preventing the child from expressing their own thoughts or feelings. It could be a sign of emotional or psychological abuse, where the child's autonomy and voice are suppressed.

B. A child who has frequent visitors: While frequent visitors may raise concerns about the child's social environment, it does not necessarily indicate abuse. Further assessment would be needed to determine the nature of these visits and their impact on the child's well-being.

C. A child who uses the call light frequently: Frequent use of the call light may indicate physical discomfort, illness, or anxiety, but it does not inherently suggest abuse. It could be related to the child's medical condition or emotional state.

D. A child who has a BMI indicating obesity: Obesity alone is not indicative of abuse. While it may raise concerns about the child's health and well-being, it does not directly point to abuse unless there are additional signs or symptoms suggestive of neglect or mistreatment.

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Correct Answer is B

Explanation

A. "This is normal behavior for infants unless the stool passed is black or green.": While black or green stools may indicate potential issues, grunting and crying during bowel movements are common behaviors in infants and are not necessarily indicative of a problem.

B. "This is normal behavior for infants due to the immaturity of the gastrointestinal system.": Grunting and crying during bowel movements are typical behaviors in infants, especially during the first few months of life. This is because the infant's gastrointestinal system is still developing and they may have difficulty coordinating their muscles to pass stool smoothly.

C. "This is normal behavior for infants unless the stool passed is hard and dry.": While hard and dry stools may indicate constipation, grunting and crying during bowel movements can still be normal behaviors in infants, regardless of the consistency of the stool.

D. "This indicates a blockage in the intestine and must be reported to the health care provider.": Grunting and crying during bowel movements are not necessarily indicative of a blockage in the intestine. These behaviors are common in infants and usually resolve as the infant's gastrointestinal system matures.

A. Substituting cow's milk if breast milk is not available B. Advising fluid intake per feeding of 5 or 6 ounces C. Advocating iron supplements with bottle-feeding D. Discouraging the addition of fruit juice to the diet

Correct Answer is D

Explanation

A. Substituting cow's milk if breast milk is not availablE. Cow's milk is not recommended as a substitute for breast milk or infant formula for infants under 12 months old due to its low iron content and potential for causing gastrointestinal irritation.

B. Advising fluid intake per feeding of 5 or 6 ounces: The appropriate fluid intake for a 2-week- old infant is typically guided by feeding cues and may vary from feeding to feeding. Providing a specific volume of fluid per feeding may not be appropriate, as infants should be fed on demand.

C. Advocating iron supplements with bottle-feeding: Iron supplementation is generally recommended for breastfed infants starting at around 4 months of age, but it is not typically necessary for formula-fed infants during the first few weeks of life. Additionally, iron

supplementation should be prescribed and monitored by a healthcare provider rather than advocated as a general guideline.

D. Discouraging the addition of fruit juice to the diet: This is the most effective anticipatory guidance because it aligns with current recommendations from pediatric healthcare

organizations. Fruit juice offers little nutritional value for infants and can contribute to dental caries and excessive calorie intake. It is generally recommended to avoid giving fruit juice to infants under 1 year old.

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A nurse is providing care to children on a general pediatric unit. Which of the following children should the nurse identify as a potential victim of abuse?

Nursing Test Bank

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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