ATI RN
Nursing Care of Children ATI
1. A child with nephrotic syndrome is severely edematous. The primary healthcare provider has placed the child on bed rest. Which nursing intervention should be included in the plan of care?
- A. Monitor blood pressure every 30 minutes.
- B. Reposition the child every two hours.
- C. Limit visitors.
- D. Encourage fluids.
Correct answer: B
Rationale: Repositioning the child every two hours is essential to prevent pressure ulcers and promote circulation, especially when the child is on bed rest and experiencing severe edema. Monitoring blood pressure is important but does not need to be done every 30 minutes unless indicated. Limiting visitors and encouraging fluids are not directly related to managing edema and preventing complications from immobility. Therefore, choice B is the most appropriate nursing intervention in this scenario.
2. A child is admitted with acute glomerulonephritis. What should the nurse expect the urinalysis during this acute phase to show?
- A. Bacteriuria and hematuria
- B. Hematuria and proteinuria
- C. Bacteriuria and increased specific gravity
- D. Proteinuria and decreased specific gravity
Correct answer: B
Rationale: Hematuria (blood in the urine) and proteinuria (protein in the urine) are common findings in acute glomerulonephritis due to inflammation of the glomeruli. Bacteriuria and changes in specific gravity are not as directly associated with this condition.
3. What is an important priority in dealing with the child suspected of having Wilms tumor?
- A. Intervening to minimize bleeding
- B. Monitoring temperature for infection
- C. Ensuring the abdomen is protected from palpation
- D. Teaching parents how to manage parenteral nutrition
Correct answer: C
Rationale: The correct priority in dealing with a child suspected of having Wilms tumor is ensuring the abdomen is protected from palpation. Palpating the abdomen could lead to tumor dissemination, which is crucial to prevent the spread of cancerous cells. Intervening to minimize bleeding, monitoring temperature for infection, and teaching parents how to manage parenteral nutrition are not the immediate priorities in suspected cases of Wilms tumor.
4. One of the most critical needs of the infant is control of body temperature. The nurse caring for a newborn warms all equipment that comes in direct contact with the newborn to help prevent which type of heat loss?
- A. Convection
- B. Evaporation
- C. Conduction
- D. Radiation
Correct answer: C
Rationale: The correct answer is Conduction (choice C). Conduction heat loss occurs when the newborn’s skin comes into direct contact with a cooler surface, so warming equipment helps prevent this. Choice A, Convection, is the transfer of heat through air or water currents, not direct contact. Choice B, Evaporation, is the loss of heat through moisture on the skin evaporating, not direct contact. Choice D, Radiation, is the transfer of heat in the form of waves or particles, not direct contact.
5. What is the recommended method to assess hydration status in infants?
- A. Capillary refill time
- B. Skin turgor
- C. Urine output
- D. Mucous membranes
Correct answer: C
Rationale: The correct answer is C: Urine output. Assessing urine output is a recommended method to determine hydration status in infants. Adequate urine output indicates good hydration, while decreased urine output may suggest dehydration. Capillary refill time (Choice A) is more indicative of circulatory status rather than hydration. Skin turgor (Choice B) is a useful assessment in adults but can be less reliable in infants. Checking mucous membranes (Choice D) can provide some information on hydration, but it is not as reliable as assessing urine output in infants.
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