superficial palpation of the abdomen is often perceived by the child as tickling which measure by the nurse is most likely to minimize this sensation
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Nursing Elites

ATI RN

ATI Nursing Care of Children

1. Superficial palpation of the abdomen is often perceived by the child as tickling. Which measure by the nurse is most likely to minimize this sensation and promote relaxation?

Correct answer: D

Rationale: Allowing the child to place their hand over the nurse's hand helps reduce the tickling sensation and increases the child's comfort during the examination.

2. What type of shock is characterized by a hypersensitivity reaction causing massive vasodilation and capillary leaks, which may occur with drug or latex allergy?

Correct answer: D

Rationale: Anaphylactic shock is a severe allergic reaction that causes massive vasodilation and increased capillary permeability, leading to rapid fluid shifts and circulatory collapse if not treated promptly. Neurogenic, cardiogenic, and hypovolemic shocks have different etiologies.

3. 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.

4. What is the first step in managing a child with anaphylaxis?

Correct answer: C

Rationale: The correct answer is to administer epinephrine. Administering epinephrine is the crucial first step in managing anaphylaxis as it helps reverse the severe allergic reaction by constricting blood vessels and relaxing airway muscles, preventing a life-threatening situation. Antihistamines (Choice A) are not the first-line treatment for anaphylaxis and should not delay the administration of epinephrine. Establishing IV access (Choice B) may be necessary but is not the initial step in managing anaphylaxis. Monitoring vital signs (Choice D) is important but should not take precedence over administering epinephrine in the acute management of anaphylaxis.

5. The nurse is performing an assessment on a 10-week-old infant. The nurse understands that the developmental characteristic of hearing at this age is which?

Correct answer: C

Rationale: By 10 weeks, infants typically turn their heads to the side to locate the source of a sound made at ear level.

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