ATI RN
Nursing Care of Children ATI
1. The apnea monitor alarm sounds on a neonate for the third time during this shift. What is the priority action by the nurse?
- A. Provide tactile stimulation.
- B. Administer 100% oxygen.
- C. Investigate possible causes of a false alarm.
- D. Assess infant for color and presence of respirations.
Correct answer: D
Rationale: The priority action for the nurse when the apnea monitor alarm sounds on a neonate is to assess the infant for color and the presence of respirations. This initial assessment helps determine the infant's respiratory status and the need for immediate intervention. Providing tactile stimulation or administering oxygen should only be done after assessing the infant's respiratory status. Investigating possible causes of a false alarm comes after ensuring the infant's well-being through the initial assessment.
2. What nursing consideration is most important when caring for a child with end-stage renal disease (ESRD)?
- A. Children with ESRD usually adapt well to minor inconveniences of treatment.
- B. Children with ESRD require extensive support until they outgrow the condition.
- C. Multiple stresses are placed on children with ESRD and their families until the illness is cured.
- D. Multiple stresses are placed on children with ESRD and their families because children's lives are maintained by drugs and artificial means.
Correct answer: D
Rationale: ESRD places significant stress on both the child and the family due to the ongoing need for dialysis, medications, and lifestyle restrictions, making it important for healthcare providers to offer extensive support and resources to manage these challenges.
3. What interventions should be implemented to maintain the skin integrity of a preterm infant born at 30 weeks?
- A. Avoid cleaning the skin
- B. Bathe the infant with sterile water
- C. Cleanse the skin with a gentle alkaline-based soap and water
- D. Thoroughly rinse the skin with plain water after bathing
Correct answer: B
Rationale: The correct intervention to maintain the skin integrity of a preterm infant born at 30 weeks is to bathe the infant with sterile water. Bathing with sterile water or a neutral pH solution is recommended to protect the delicate skin of preterm infants, which is more permeable and prone to damage. Choices A, C, and D are incorrect as avoiding cleaning the skin may lead to hygiene issues, cleansing with alkaline-based soap can be harsh on the delicate skin, and thoroughly rinsing with plain water after bathing may not be as gentle and protective for preterm infants.
4. A child is admitted with acute glomerulonephritis. What should the nurse expect the urinalysis during this acute phase to show?
- A. Bacteriuria and hematuria
- B. Hematuria and proteinuria
- C. Bacteriuria and increased specific gravity
- D. Proteinuria and decreased specific gravity
Correct answer: B
Rationale: Hematuria (blood in the urine) and proteinuria (protein in the urine) are common findings in acute glomerulonephritis due to inflammation of the glomeruli. Bacteriuria and changes in specific gravity are not as directly associated with this condition.
5. Which statement regarding bottle mouth caries requires further teaching?
- A. Caries can be decreased by putting an infant to bed with a bottle of milk or sweetened juice
- B. Eliminating the bedtime bottle or substituting water is recommended
- C. Sugar pools within the oral cavity cause severe decay
- D. It is often seen in children between 18 months and 3 years
Correct answer: A
Rationale: The correct answer is A. Putting an infant to bed with a bottle of milk or sweetened juice increases the risk of bottle mouth caries rather than decreasing it. This statement requires further teaching as it provides incorrect information. Choice B is correct as eliminating the bedtime bottle or substituting water is recommended to prevent bottle mouth caries. Choice C is also correct as sugar pooling within the oral cavity can indeed cause severe decay. Choice D is correct as bottle mouth caries is often observed in children between 18 months and 3 years.
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