ATI RN
ATINur2708 Pediatrics Final Exam Questions
Extract:
11-month-old infant reportedly fell down a flight of stairs from the porch to the sidewalk. CT scan shows small subdural hematoma. Admit for close observation. Vital Signs Admission: Axillary temperature 37.1° C (98.8° F), Apical heart rate 104/min, Respiratory rate 26/min, Oxygen saturation 98% on room air. 4 hr later: Axillary temperature 38.2° C (100.8° F), Apical heart rate 124/min, Respiratory rate 22/min, Oxygen saturation 96% on room air. Nurses' Notes Admission note: Infant alert and fussy in guardian's arms. Moves all extremities. Edema and ecchymosis noted on left side of scalp. Anterior fontanel level and soft. Pupils equal and react briskly to light. 4 hr later: Infant sleeping in guardian's arms. Guardian reports they are unable to wake the infant to feed them. Infant slept through vital sign assessment.
Question 1 of 5
A nurse is caring for an infant in the emergency department. Which of the following actions should the nurse take?
Correct Answer: A,B,C,E
Rationale: A: Stabilizing the spine is critical due to the fall, which poses a risk of spinal injury. B: Palpating the fontanel monitors for increased intracranial pressure, especially with a hematoma. C: Assessing pupillary reaction evaluates neurological status, crucial given the infant's unresponsiveness. E: Measuring head circumference tracks potential swelling from the hematoma. D is incorrect as feeding an unresponsive infant risks aspiration. F is less urgent compared to other actions.
Extract:
School-age child with full-thickness burns to 30% of the total body surface area (TBSA). Vital Signs: Oral temperature 38° C (100.2°F), Respiratory rate 34/min, Heart rate 115/min, Blood pressure 86/54 mm Hg, SaO2 94%. Medication: Lactated Ringer's IV, Fentanyl 28 mcg IV prn, Silver sulfadiazine topically. Physical Examination: 30% TBSA burns to bilateral lower extremities, 4+ edema, sluggish capillary refill, nonpalpable pedal pulses.
Question 2 of 5
A nurse is initiating the client's plan of care. Complete the following sentence by using the list of options. The client is at highest risk for developing as evidenced by the client's
Correct Answer: A,B
Rationale: A: Acute kidney injury is a risk due to hypoperfusion from burns and shock. B: Monitoring urine output (30 mL/hr goal) assesses renal function, a key indicator of kidney injury risk.
Extract:
Child with suspected bacterial meningitis.
Question 3 of 5
A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?
Correct Answer: C
Rationale: C: Placing the child in isolation is the priority to prevent the spread of highly contagious bacterial meningitis.
Extract:
Infant with myelomeningocele before surgical intervention.
Question 4 of 5
A new graduate nurse is caring for an infant with myelomeningocele before surgical intervention. Which action will demonstrate the need for further education by their preceptor?
Correct Answer: A
Rationale: A: Keeping the myelomeningocele uncovered and dry increases infection risk; it should be covered with a moist, sterile dressing, indicating a need for further education.
Extract:
5-year-old child with meningitis.
Question 5 of 5
A nurse is caring for a 5 year old child with meningitis. Which of the following signs or symptoms may indicate increased intracranial pressure in this child?
Correct Answer: C
Rationale: C: Headache and vomiting are classic signs of increased intracranial pressure in a 5-year-old with meningitis.