ATI RN
ATI RN Pediatric Nursing 2023 Exam 3 Questions
Extract:
Question 1 of 5
A nurse is assessing a 4-month-old infant during a well-baby visit. For which of the following findings should the nurse notify the provider?
Correct Answer: B
Rationale: The correct answer is B: Doll's eye reflex intact. This reflex, also known as oculocephalic reflex, should not be present in infants beyond 3 months old. It involves the eyes moving in the opposite direction of head movement, which is abnormal in older infants. This finding could indicate a neurological issue and should be reported to the provider for further evaluation.
Choice A is normal as lack of head lag at 4 months indicates appropriate muscle tone.
Choice C is normal as infants should start producing tears when crying around this age.
Choice D is normal in infants under 2 years old as the Babinski reflex is present until this age.
Question 2 of 5
A nurse is applying soft limb restraints to a child who is acting aggressively toward staff. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Secure the restraints with a quick-release knot. This is important for the safety of the child as quick-release knots allow for easy removal in case of an emergency. Tying restraints to the side rails (option
A) can increase the risk of injury. Requesting prescription renewal every 48 hours (option
B) is important but not the immediate action needed. Assessing the child every 4 hours (option
D) is essential but secondary to ensuring proper restraint application.
Question 3 of 5
A nurse is reviewing the complete blood count results for a 4-year-old child who is receiving treatment for acute lymphoblastic leukemia. Which of the following findings should indicate to the nurse that the treatment is having a therapeutic effect?
Correct Answer: C
Rationale: The correct answer is C: RBC count 5/mm3 (4 to 5.5/mm3). In the context of acute lymphoblastic leukemia treatment, a therapeutic effect is indicated by a normal or near-normal RBC count. This is because leukemia often leads to suppression of normal blood cell production, resulting in low RBC counts.
Therefore, an RBC count within the normal range suggests that the treatment is effectively targeting the leukemia cells and allowing the bone marrow to produce healthy red blood cells.
Choice A is incorrect because a hemoglobin level of 6.8 g/dL is low, indicating anemia, which is a common side effect of leukemia and not a sign of therapeutic effect.
Choice B is incorrect because a platelet count of 98,000/mm3 is below the normal range and indicates thrombocytopenia, which is also a common side effect of leukemia treatment.
Choice D is incorrect because a WBC count of 15,000/mm3
Question 4 of 5
A nurse is caring for a 5-year-old child who has acute poststreptococcal glomerulonephritis. Which of the following findings should indicate to the nurse that treatment has been effective?
Correct Answer: C
Rationale: The correct answer is C: Clear urine. In acute poststreptococcal glomerulonephritis, the kidneys become inflamed and may present with hematuria and proteinuria. Clear urine indicates resolution of these symptoms, reflecting improved kidney function. A: Temperature and D: Odorless urine are unrelated to the condition. B: No pain with voiding is important but not a direct indicator of treatment effectiveness. Other choices are not relevant.
Question 5 of 5
A nurse is caring for a 1-week-old newborn who has hyperbilirubinemia and is being treated with phototherapy. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Monitor the newborn's temperature every 2 hr. Hyperbilirubinemia can lead to increased risk of hypothermia during phototherapy. Monitoring temperature every 2 hours is crucial to detect any signs of hypothermia early and prevent complications. Checking the newborn's eyes every 8 hours (
A) is not directly related to managing hyperbilirubinemia or phototherapy. Placing mittens on the newborn's hands (
B) is not necessary for this situation. Applying lotion to the newborn's skin (
D) is not indicated and can interfere with phototherapy.