ATI RN
ATI Nursing Care of Children
1. The nurse is testing an infant's visual acuity. By which age should the infant be able to fix on and follow a target?
- A. 1 month
- B. 1 to 2 months
- C. 3 to 4 months
- D. 6 months
Correct answer: C
Rationale: By 3 to 4 months of age, an infant should be able to fix on and follow a target, indicating proper visual development.
2. 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.
3. With the National Center for Health Statistics criteria, which body mass index (BMI)-for-age percentiles should indicate the patient is at risk for being overweight?
- A. 10th percentile
- B. 75th percentile
- C. 85th percentile
- D. 95th percentile
Correct answer: C
Rationale: A BMI-for-age at the 85th percentile indicates a child is at risk for being overweight, according to the National Center for Health Statistics criteria.
4. A mother tells the nurse that she does not want her infant immunized because of the discomfort associated with injections. What should the nurse explain?
- A. This cannot be prevented
- B. Infants do not feel pain as adults do
- C. This is not a good reason for refusing
- D. A topical anesthetic can be applied
Correct answer: D
Rationale: The nurse should explain that a topical anesthetic can be applied to the injection site before the immunization to reduce discomfort.
5. Superficial palpation of the abdomen is often perceived by the child as tickling. Which measure by the nurse is most likely to minimize this sensation and promote relaxation?
- A. Palpate another area simultaneously
- B. Ask the child not to laugh or move
- C. Begin with deeper palpation and gradually progress to superficial palpation
- D. Have the child help with palpation by placing his or her hand over the palpating hand
Correct answer: D
Rationale: Allowing the child to place their hand over the nurse's hand helps reduce the tickling sensation and increases the child's comfort during the examination.
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