ATI RN
RN Nursing Care of Children 2019 With NGN
1. A 14-month-old child is admitted to the hospital with laryngotracheobronchitis (LTB). Which assessment findings should the nurse expect?
- A. Cyanosis and dyspnea
- B. Productive cough and high fever
- C. Barking cough and inspiratory stridor
- D. Pale laryngeal and dyspnea
Correct answer: C
Rationale: The correct answer is C: 'Barking cough and inspiratory stridor.' Classic signs of laryngotracheobronchitis (LTB) include a barking cough, often described as a seal-like cough, and inspiratory stridor, which is a high-pitched sound heard during inspiration. These symptoms occur due to inflammation and narrowing of the upper airway. Choices A, B, and D are incorrect as they do not align with the typical assessment findings of LTB. Cyanosis and dyspnea (Choice A) may occur in severe cases but are not specific to LTB. Productive cough and high fever (Choice B) are more indicative of lower respiratory tract infections. Pale laryngeal and dyspnea (Choice D) are not characteristic findings of LTB.
2. Chemicals, agents, or factors that cause physical defects in the developing embryo and are most harmful during organogenesis are:
- A. Teratogens
- B. Heterozygous
- C. Inborn errors
- D. Multifactorial
Correct answer: A
Rationale: Teratogens are substances that can cause congenital abnormalities, especially during the first trimester when organogenesis occurs. Choice A, Teratogens, is the correct answer as it specifically refers to substances that cause physical defects in the developing embryo. Choices B, Heterozygous, C, Inborn errors, and D, Multifactorial, are incorrect as they do not directly relate to substances that cause physical defects in embryos during organogenesis.
3. What statement is most descriptive of Meckel diverticulum?
- A. It is present from birth.
- B. Intestinal bleeding may be mild or profuse.
- C. It occurs with equal frequency in both genders.
- D. Surgical interventions are always necessary to treat the problem.
Correct answer: B
Rationale: The correct answer is B. Meckel diverticulum often presents with intestinal bleeding, which can vary in severity. It is a congenital condition, meaning it is present from birth, not acquired during childhood (choice A). Meckel diverticulum is slightly more common in males than in females, so it does not occur more frequently in females (choice C). While some cases of Meckel diverticulum may require surgical intervention, medical interventions can also be sufficient to treat the problem, so it is not always necessary to resort to surgery (choice D).
4. In the newborn, into what muscle is intramuscular vitamin K administered?
- A. Deltoid
- B. Dorsogluteal
- C. Rectus femoris
- D. Vastus lateralis
Correct answer: D
Rationale: In newborns, intramuscular vitamin K is traditionally administered into the vastus lateralis muscle. This site is preferred due to its large muscle mass and accessibility. The dorsogluteal site is not recommended for newborns due to the risk of injury to the sciatic nerve. The deltoid site is also not recommended for newborns. The rectus femoris muscle is not commonly used for intramuscular injections in newborns.
5. An infant, age 6 months, has six teeth. The nurse should recognize that this is what?
- A. Normal tooth eruption
- B. Delayed tooth eruption
- C. Unusual and dangerous
- D. Earlier than expected tooth eruption
Correct answer: D
Rationale: Having six teeth at 6 months is earlier than the typical tooth eruption schedule, but it is not unusual or dangerous. It is within the range of normal variations in infant development.