ATI RN
ATI RN Nursing Care of Children 2019 Questions
Extract:
Child with acute epiglottitis
Question 1 of 5
A nurse is admitting a child who has acute epiglottitis. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Initiate droplet isolation precautions. This is important in the case of acute epiglottitis, as it is a serious condition that can lead to airway obstruction. By implementing droplet precautions, the nurse can help prevent the spread of infection to others. Obtaining a throat culture (
A) is important but not the priority in this urgent situation. Placing the child in a supine position (
C) can worsen the airway obstruction. Checking oxygen saturation every 4 hours (
D) is essential but not the immediate action needed to manage acute epiglottitis.
Extract:
10-year-old child scheduled for an arterial cardiac catheterization
Question 2 of 5
A nurse is providing teaching to a 10-year-old child who is scheduled for an arterial cardiac catheterization. Which of the following information should the nurse include in the teaching?
Correct Answer: A
Rationale: The correct answer is A: "You will need to keep your leg straight for 8 hours following the procedure." This is important because maintaining the leg straight helps prevent bleeding from the catheter insertion site. Keeping the leg straight for 8 hours allows the blood vessel to heal and prevents complications.
Explanation for incorrect choices:
B: Having the dressing removed 12 hours after the procedure is not accurate as the dressing is typically removed after a few hours to assess the insertion site.
C: Being on a clear liquid diet for 24 hours is not necessary for this procedure as it does not directly impact the outcome.
D: Being on bed rest for 2 days after the procedure is excessive and not recommended as early mobilization is encouraged to prevent complications.
Extract:
15-month-old child scheduled for MMR vaccine
Question 3 of 5
A nurse is reviewing the medical record of a 15-month-old child who is scheduled to receive the measles, mumps, and rubella (MMR) vaccine. Which of the following findings should the nurse identify as a contraindication for receiving this vaccine?
Correct Answer: A
Rationale:
Correct
Answer: A: Allergy to neomycin.
Rationale: Neomycin is an antibiotic that is present in the MMR vaccine as a preservative. An allergy to neomycin is a contraindication for receiving the MMR vaccine due to the risk of an allergic reaction. It is crucial to avoid administering the vaccine in individuals with known allergies to any component of the vaccine.
Summary of other choices:
B: Family history of seizures is not a contraindication for the MMR vaccine.
C: An upper respiratory infection 2 days ago is not a contraindication unless the child is currently ill.
D: A temperature of 37.2°C (99°F) is slightly elevated but not a contraindication unless the child has a fever over 38.5°C (101.3°F).
Extract:
Infant receiving opioids for pain
Question 4 of 5
A nurse is monitoring an infant who is receiving opioids for pain. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect?
Correct Answer: B
Rationale: The correct answer is B: Relaxed facial expression. In infants receiving opioids for pain, a relaxed facial expression indicates pain relief, as opioids work to decrease pain sensation. Bradycardia (
A) and increased blood pressure (
C) are common side effects of opioids and do not necessarily indicate therapeutic effect. Limb withdrawal (
D) may be a reflexive response and not a reliable indicator of pain relief.
Therefore, a relaxed facial expression is the most reliable sign that the medication is having a therapeutic effect.
Extract:
5-month-old infant
Question 5 of 5
A nurse is assessing a 5-month-old infant. Which of the following findings should the nurse report to the provider?
Correct Answer: D
Rationale: The correct answer is D: Exhibits head lag when pulled to a sitting position. This finding indicates poor head control, which is a developmental red flag at 5 months. It suggests possible neuromuscular weakness or delay, necessitating further evaluation by the provider.
Choices A, B, and C are typical developmental milestones at 5 months. Absence of grasp reflex is expected as it disappears by 3 months. Inability to hold a bottle can be normal at this age, and rolling from back to abdomen usually begins around 5-6 months.
Therefore, these findings are not concerning at this stage of development.