ATI RN
ATI RN Nursing Care of Children 2019 Questions
Extract:
15-month-old child scheduled for MMR vaccine
Question 1 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 2 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 3 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.
Extract:
Infant with new prescription for digoxin
Question 4 of 5
A nurse in a pediatric clinic is providing teaching to the guardian of an infant who has a new prescription for digoxin. Which of the following manifestations should the nurse include as an indication of digoxin toxicity?
Correct Answer: C
Rationale:
Rationale: Digoxin toxicity commonly presents with bradycardia due to its effect on the heart's electrical conduction system. This can lead to arrhythmias and cardiac arrest. Polyuria, diaphoresis, and jaundice are not typical manifestations of digoxin toxicity. Polyuria and diaphoresis are more commonly seen with conditions like diabetes or hyperthyroidism. Jaundice is not a typical sign of digoxin toxicity. In summary, bradycardia is the key indicator of digoxin toxicity, making choice C the correct answer.
Extract:
Infant with severe dehydration due to gastroenteritis
Question 5 of 5
A nurse is assessing an infant who has severe dehydration due to gastroenteritis. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: Increased respiratory rate. Severe dehydration leads to hypovolemia, causing the body to compensate by increasing the respiratory rate to maintain oxygen levels. Hypertension (
A) is unlikely due to decreased fluid volume. Increased urine output (
B) is not expected in dehydration. Capillary refill of 2 seconds (
C) indicates good perfusion, which is not expected in severe dehydration.
Therefore, the correct answer is D as it reflects the body's compensatory mechanism in response to dehydration.