ATI RN
Nursing Care of Children ATI
1. The nurse is caring for a 1-month-old infant diagnosed with Hirschsprung’s disease. Which treatment measure should be included in the plan of care?
- A. Barium Enema
- B. Surgical removal of the affected section of bowel
- C. High-fiber diet
- D. Permanent colostomy
Correct answer: B
Rationale: The correct answer is B: Surgical removal of the affected section of bowel. Hirschsprung's disease is a congenital condition where a portion of the large intestine lacks nerve cells, leading to difficulties in passing stool. The definitive treatment for this condition is the surgical removal of the affected section of the bowel. Barium enema (Choice A) may be used for diagnosis but is not a treatment. A high-fiber diet (Choice C) is not effective in managing Hirschsprung's disease. A permanent colostomy (Choice D) is not the initial treatment for this condition in infants.
2. The nurse is caring for a child after a cleft palate repair who is on a clear liquid diet. Which feeding device should the nurse use to deliver the clear liquid diet?
- A. Straw
- B. Spoon
- C. Sippy cup
- D. Open cup
Correct answer: D
Rationale: An open cup is recommended for feeding after cleft palate repair to prevent injury to the surgical site and avoid creating negative pressure, which could disrupt the repair.
3. Which medication should the nurse expect to administer to a child with an acute sickle cell pain crisis?
- A. Meperidine (Demerol)
- B. Morphine
- C. Acetaminophen (Tylenol)
- D. Ibuprofen (Motrin)
Correct answer: B
Rationale: In the management of acute sickle cell pain crisis in children, morphine is the preferred medication due to its effectiveness in providing pain relief. Meperidine (Demerol) is less commonly used in this scenario because of its potential for neurotoxicity with repeated doses. Acetaminophen (Tylenol) and Ibuprofen (Motrin) are not typically sufficient for managing the severe pain associated with sickle cell crises and are not the first-line treatment options.
4. The nurse is caring for a very low-birth-weight (VLBW) infant with a peripheral intravenous infusion. What nursing considerations regarding infiltration should be included in planning IV care?
- A. Infiltration is not solely related to the activity level of VLBW infants.
- B. Continuous infusion pumps do not always stop automatically when infiltration occurs.
- C. Hypertonic solutions can cause severe tissue damage if infiltration occurs.
- D. The infusion site should be checked regularly to prevent infiltration-related complications.
Correct answer: C
Rationale: Hypertonic solutions can damage tissues if they leak from the vein due to infiltration. It is crucial to monitor for this complication to prevent severe tissue damage. Infiltration is not solely related to the activity level of VLBW infants; it can occur due to various reasons such as vein condition, catheter placement, and fluid type. Continuous infusion pumps may not always detect infiltration, as they typically alarm for pressure changes but not all infiltration instances. Checking the infusion site regularly, preferably hourly, is essential to prevent complications like tissue damage from extravasations, fluid overload, and dehydration.
5. The LPN is assessing for fontanels on the head of a 6-month-old. Which fontanel is expected to still be present?
- A. Posterior
- B. Anterior
- C. Sphenoid
- D. Lambdoid
Correct answer: B
Rationale: The correct answer is B: Anterior. The anterior fontanel usually remains open until about 12-18 months of age, while the posterior fontanel closes by 2-3 months. Choices A, C, and D are incorrect as the posterior fontanel closes by 2-3 months of age, and the sphenoid and lambdoid fontanels are not typically assessed in routine infant head examinations.
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