ATI RN
ATI Nursing Care of Children
1. Baby M is 5 months old. You notice that she now has the ability to grasp objects between her fingers and opposing thumb. This is known as:
- A. Parachute reflex
- B. Grasp reflex
- C. Pincer grasp
- D. Prehension
Correct answer: C
Rationale: The correct answer is C: Pincer grasp. The pincer grasp is the ability to hold objects between the thumb and another finger, typically developed around 9-12 months. At 5 months, it is early for a pincer grasp to fully develop, but the beginning of this skill can be seen as early as 5 months. Choices A and B are incorrect as the parachute reflex is a protective response to falling and the grasp reflex is an automatic response to touch. Choice D, prehension, is a general term for the act of grasping or holding objects, but it does not specifically refer to holding objects between the thumb and fingers like the pincer grasp does.
2. The nurse is taking a health history of an adolescent. Which best describes how the chief complaint should be determined?
- A. Request a detailed listing of symptoms.
- B. Ask the adolescent, "Why did you come here today?"
- C. Interview the parent away from the adolescent to determine the chief complaint
- D. Use what the adolescent says to determine, in correct medical terminology, what the problem is
Correct answer: B
Rationale: Asking the adolescent directly about the reason for their visit encourages open communication and helps the nurse understand the primary concern from the patient's perspective.
3. According to Piaget, which principle supports a nine-year-old child's understanding that an arm will look the same when the IV is removed?
- A. The principle of conservation
- B. The principle of transductive reasoning
- C. The principle of identity
- D. The principle of reflex abilities
Correct answer: A
Rationale: The correct answer is A, the principle of conservation. Piaget's principle of conservation relates to a child's ability to understand that certain properties of objects remain unchanged despite modifications in their appearance. In this case, the child's understanding that an arm will look the same after the IV is removed demonstrates conservation of appearance. Choice B, transductive reasoning, involves making faulty generalizations based on specific instances and does not apply in this context. Choice C, the principle of identity, pertains to recognizing objects as the same even if they undergo transformations, which is not directly relevant to the scenario. Choice D, reflex abilities, refers to automatic responses to stimuli and is unrelated to the child's understanding of the arm's appearance post-IV removal.
4. The parents of a 5-year-old child ask the nurse how they can minimize misbehavior. Which responses should the nurse give? (Select all that apply.)
- A. Set clear and reasonable goals
- B. Teach desirable behavior through your own example
- C. Don’t call attention to unacceptable behavior
- D. All of the above
Correct answer: D
Rationale: Setting clear goals, praising good behavior, and modeling appropriate behavior are effective strategies for minimizing misbehavior in children.
5. What is the appropriate site to administer an intramuscular (IM) vaccine to a newborn?
- A. The dorsal gluteal muscle
- B. The vastus lateralis muscle
- C. The ventral gluteal muscle
- D. The biceps muscle
Correct answer: B
Rationale: The correct site to administer an intramuscular (IM) vaccine to a newborn is the vastus lateralis muscle. For newborns, the vastus lateralis is preferred over the dorsogluteal site because the dorsogluteal site has been associated with low antibody seroconversion rates, indicating a reduced immune response. The vastus lateralis is also recommended for IM injections in newborns, while the deltoid muscle is preferred for older infants and children. The ventral gluteal muscle and the biceps muscle are not appropriate sites for IM injections. Therefore, choice B is the correct answer.
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