ATI RN
RN Nursing Care of Children 2019 With NGN
1. Parents would suspect hearing loss if their child did not:
- A. Turn away from a sound
- B. Startle with sudden loud noises immediately after birth
- C. Talk at 4 months
- D. Babble at 2 months
Correct answer: D
Rationale: The correct answer is D because babbling is an early indicator of hearing ability in infants. Lack of babbling by 2 months may suggest a potential hearing issue. Choices A, B, and C are incorrect because turning away from a sound, startling with sudden loud noises immediately after birth, and talking at 4 months are not primary indicators of hearing loss in infants.
2. Pertussis vaccination should begin at which age?
- A. Birth
- B. 2 months
- C. 6 months
- D. 12 months
Correct answer: B
Rationale: The DTaP vaccine, which includes pertussis, is typically started at 2 months of age as part of the recommended immunization schedule.
3. 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.
4. A 12-month-old infant has been diagnosed with failure to thrive (FTT). Which assessment findings does the nurse expect to be documented with this infant?
- A. Fear of strangers
- B. Minimal smiling
- C. Avoidance of eye contact
- D. All of the above
Correct answer: D
Rationale: These behaviors are consistent with FTT and indicate social withdrawal, which is often observed in infants who are not thriving. A wide-eyed gaze and avoidance of eye contact can also indicate developmental delays or emotional disturbances.
5. 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.