ATI LPN
ATI PN Pediatrics nursing 2023 III Questions
Question 1 of 5
A nurse is monitoring a 6-month-old infant 20 minutes after administering a hepatitis B immunization. Which of the following findings is the nurse's priority?
Correct Answer: C
Rationale: Redness at the injection site is a common and expected local reaction following immunization. It typically resolves on its own without intervention. A temperature of 37.7°C (99.9°F) is a mild fever and a common response to immunizations as the body mounts an immune response. Hives on the child's neck is the priority finding because it can indicate an allergic reaction, which may progress to anaphylaxis, a severe, life-threatening condition requiring immediate intervention. Prolonged crying can be a sign of discomfort or pain but is not as urgent as signs of an allergic reaction.
Question 2 of 5
A nurse is preparing to administer medications to a 5-month-old infant. Tympanic temperature 39.2°C (102.6°F). Heart rate 84/min. Respiratory rate 30/min. Blood pressure 80/30 mmHg. Oxygen saturation 96% on 0.5 L oxygen via nasal cannula. Weight 7.2 kg (15.9 lb). The nurse should clarify the prescription for which medication?
Correct Answer: A
Rationale: Ibuprofen should be clarified before administration to a 5-month-old infant as it is not recommended for infants younger than 6 months due to risks of nephrotoxicity and gastrointestinal irritation. Acetaminophen is safe for infants to reduce fever. Heart rate and temperature are vital signs, not medications, and do not require clarification as prescriptions.
Question 3 of 5
A nurse is assisting with the care of a school-age child who is terminally ill. Which of the following interventions should the nurse perform?
Correct Answer: C
Rationale: Collecting vital signs every 2 hours may increase stress without providing comfort. Avoiding death discussions limits open communication. Encouraging sibling involvement fosters emotional support and family unity, beneficial for end-of-life care. Passive range of motion is secondary to comfort measures.
Question 4 of 5
A nurse is caring for a child and suspects the child has experienced physical maltreatment. Which of the following statements should the nurse make?
Correct Answer: C
Rationale: Saying 'This should not have happened' validates injustice but lacks comfort. Promising confidentiality is unethical due to mandatory reporting. 'It is not your fault' reassures the child, reducing guilt and shame, crucial for emotional support. Blaming the child for not reporting sooner is unsupportive.
Question 5 of 5
A nurse is collecting data from an infant. Which of the following areas should the nurse palpate to check for an inguinal hernia?
Correct Answer: A
Rationale: Palpating the groin area detects inguinal hernias, where intestines protrude through abdominal muscles. The abdomen, lower back, and upper thigh are not specific sites for this condition.