ATI RN
Nursing Care of Children ATI
1. At a well-child check-up, the nurse notes that an infant with a previous diagnosis of failure to thrive (FTT) is now steadily gaining weight. The nurse should recommend that fruit juice intake be limited to no more than how much?
- A. 4 oz/day
- B. 6 oz/day
- C. 8 oz/day
- D. 12 oz/day
Correct answer: A
Rationale: The American Academy of Pediatrics recommends limiting fruit juice intake to no more than 4 oz per day for infants, as excessive juice can contribute to poor nutrition and dental issues.
2. Which nursing intervention should be included in the postoperative care of a child following a tonsillectomy?
- A. Encourage the child to blow the nose gently
- B. Notify the physician if mucus is observed in the emesis
- C. Position the child supine in the immediate postoperative period
- D. Avoid giving citrus juice
Correct answer: D
Rationale: The correct answer is D: 'Avoid giving citrus juice.' Citrus juice can irritate the throat after a tonsillectomy, so it should be avoided. Choice A is incorrect because blowing the nose gently is not a recommended intervention following a tonsillectomy. Choice B is incorrect as mucus in emesis is not uncommon postoperatively and does not necessarily require physician notification. Choice C is incorrect as positioning the child supine immediately postoperatively can increase the risk of airway obstruction and should be avoided.
3. The caregiver asks why the 6-month-old infant needs to have solid foods when breast milk is such a good source of nutrition. What would be the best response by the nurse?
- A. Solid foods, especially iron-fortified cereals, are introduced to meet the infant's increased nutritional needs, including iron, which breast milk alone may not provide adequately.
- B. The extrusion reflex must be developed and feeding solid foods will help the infant to develop this reflex.
- C. Breastfeeding will become painful when the infant gets more teeth, so the infant needs to eat solid foods.
- D. By this age the infant becomes interested in trying new skills.
Correct answer: A
Rationale: The correct response is A. Solid foods, especially iron-fortified cereals, are introduced to meet the infant's increased nutritional needs, including iron, which breast milk alone may not provide adequately. Choice B is incorrect because the extrusion reflex is related to the tongue-thrust reflex, not the nutritional needs of the infant. Choice C is incorrect as breastfeeding does not become painful when the infant gets more teeth, and it is not a reason for introducing solid foods. Choice D is incorrect as the infant's interest in trying new skills is not a primary reason for introducing solid foods at this age.
4. Which is the most frequently used test for measuring visual acuity?
- A. Snellen letter chart
- B. Ishihara vision test
- C. Allen picture card test
- D. Denver eye screening test
Correct answer: A
Rationale: The Snellen letter chart is the most commonly used test for measuring visual acuity, particularly in school-age children and adults.
5. The nurse is caring for a child with a urinary tract infection who is on intravenous gentamicin (Garamycin). What interventions should the nurse plan for this child with regard to this medication? (Select all that apply.)
- A. Encourage fluids.
- B. Monitor urinary output.
- C. Monitor sodium serum levels.
- D. All above
Correct answer: D
Rationale: Gentamicin is an aminoglycoside antibiotic that requires monitoring of serum peak and trough levels to avoid toxicity, particularly nephrotoxicity and ototoxicity. Encouraging fluids and monitoring urinary output are also crucial to minimize the risk of kidney damage.
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