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 parameter correlates best with measurements of total muscle mass?
- A. Height
- B. Weight
- C. Skinfold thickness
- D. Upper arm circumference
Correct answer: D
Rationale: Upper arm circumference correlates best with total muscle mass because it includes both muscle and fat components, making it a reliable indicator of muscle mass.
3. 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.
4. A parent of a school-age child tells the school nurse that the parents are going through a divorce. The child has not been doing well in school and sometimes has trouble sleeping. The nurse should recognize this as what?
- A. Indicative of maladjustment
- B. A common reaction to divorce
- C. Suggestive of a lack of adequate parenting
- D. An unusual response that indicates a need for referral
Correct answer: B
Rationale: Poor academic performance and sleep disturbances are common reactions in children going through their parents' divorce, reflecting stress and adjustment challenges.
5. 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.
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