ATI RN
RN Nursing Care of Children 2019 With NGN
1. A parent calls the hospital nursing hotline and asks, 'My 8-week-old infant cries 8 hours a day, and is hard to console. Is that normal?' What should the nurse's response be to this parent?
- A. No, call your health care provider.
- B. Let me ask you some more questions to see if there are symptoms of colic.
- C. Yes, maybe your infant is just tired.
- D. Yes, infants cry all the time at that age.
Correct answer: B
Rationale: The correct response for the nurse to provide in this situation is to ask more questions to determine if the infant is displaying symptoms of colic. Colic is a common condition in infants that can lead to prolonged crying and fussiness. It is essential to assess for other symptoms before giving advice to the parent. Choices A, C, and D are incorrect because they do not address the possibility of colic or the need for further assessment of the infant's condition.
2. An infant is diagnosed with a tracheoesophageal fistula. Which assessment finding should the nurse expect?
- A. Jaundice
- B. Hyperactive bowel sounds
- C. Absence of sucking, vomiting
- D. Coughing, with excessive secretion
Correct answer: D
Rationale: Coughing with excessive secretion is a common sign of tracheoesophageal fistula. In this condition, the connection between the trachea and esophagus allows saliva and food to enter the airways, leading to coughing and excessive secretions. Choice A, jaundice, is not typically associated with tracheoesophageal fistula. Hyperactive bowel sounds (Choice B) are more likely seen in conditions like gastroenteritis. Absence of sucking and vomiting (Choice C) is not a typical finding related to tracheoesophageal fistula.
3. What is the priority nursing intervention for a child with epiglottitis?
- A. Administer antibiotics
- B. Maintain airway patency
- C. Provide hydration
- D. Monitor vital signs
Correct answer: B
Rationale: The correct answer is B: Maintain airway patency. When dealing with a child with epiglottitis, the priority nursing intervention is to ensure airway patency to prevent airway obstruction, which can lead to respiratory distress or failure. Administering antibiotics (choice A) is important to treat the infection, but airway management takes precedence. Providing hydration (choice C) and monitoring vital signs (choice D) are essential aspects of care but are secondary to securing the airway in a child with epiglottitis.
4. The nurse is providing anticipatory guidance to parents of a 4-month-old infant on preventing an aspiration injury. What should the nurse include in the teaching?
- A. Keep baby powder out of reach.
- B. Inspect toys for removable parts.
- C. Allow the infant to take a bottle to bed.
- D. Teething biscuits can be used for teething discomfort.
Correct answer: A
Rationale: Baby powder can be inhaled by the infant and cause respiratory distress. Toys should be inspected to prevent choking hazards. Allowing an infant to take a bottle to bed can increase the risk of aspiration, and hard foods like teething biscuits should be given with caution.
5. A teenager is accompanied by his mother to the annual physical examination. The nurse is aware of privacy issues related to the teenager. While the mother is in the room, which topic should the nurse avoid?
- A. School performance
- B. Seatbelt use
- C. Cigarette smoking
- D. School friends
Correct answer: C
Rationale: The correct answer is C: Cigarette smoking. Discussing sensitive topics like cigarette smoking in the presence of a parent may inhibit the teenager's willingness to be open and honest. It's important to provide an opportunity for the teenager to speak privately with the healthcare provider. Choices A, B, and D are more general topics that can be discussed openly in front of the parent without compromising the teenager's privacy or comfort.
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