during a funduscopic examination of a school age child the nurse notes a brilliant uniform red reflex in both eyes the nurse should recognize that thi
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Nursing Elites

ATI RN

ATI Nursing Care of Children

1. During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is which?

Correct answer: A

Rationale: A brilliant, uniform red reflex in both eyes is a normal finding, indicating that the retina is healthy and there are no significant obstructions in the visual pathway.

2. A school-age child is admitted to the pediatric unit with a vaso-occlusive crisis. Which of these should be included in the nursing plan of care?

Correct answer: D

Rationale: The correct answer is D. Vaso-occlusive crises in sickle cell anemia require a comprehensive approach that includes adequate hydration to reduce blood viscosity, oxygenation to prevent further sickling of red blood cells, and aggressive pain management. This approach helps improve tissue perfusion and manage pain effectively. Choices A, B, and C are incorrect. Correction of alkalosis is not a priority in vaso-occlusive crisis management. Administration of heparin is not indicated as it can increase the risk of bleeding in sickle cell patients. Factor VIII replacement is not relevant to sickle cell anemia as it is a treatment for hemophilia, not sickle cell disease.

3. At which age should the nurse expect an infant to begin smiling in response to pleasurable stimuli?

Correct answer: B

Rationale: Infants typically begin to smile in response to pleasurable stimuli by 2 months, which is an early sign of social interaction and emotional development.

4. What is the appropriate site to administer an intramuscular (IM) vaccine to a newborn?

Correct answer: B

Rationale: The correct site to administer an intramuscular (IM) vaccine to a newborn is the vastus lateralis muscle. For newborns, the vastus lateralis is preferred over the dorsogluteal site because the dorsogluteal site has been associated with low antibody seroconversion rates, indicating a reduced immune response. The vastus lateralis is also recommended for IM injections in newborns, while the deltoid muscle is preferred for older infants and children. The ventral gluteal muscle and the biceps muscle are not appropriate sites for IM injections. Therefore, choice B is the correct answer.

5. What is a common significant side effect of opioid administration?

Correct answer: C

Rationale: Constipation is one of the most common side effects of opioid administration due to the slowing down of gastrointestinal motility. Opioids affect the bowel movements, leading to constipation. Euphoria, while a possible effect, is less common than constipation. Diuresis is not a typical side effect of opioids; instead, urinary retention may occur. Allergic reactions are rare side effects of opioids, with symptoms such as rash, itching, or anaphylaxis.

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