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. An infant is suspected of having esophageal atresia/tracheoesophageal fistula. While waiting for the pediatrician to see the infant, which action should the nurse take?
- A. Position the infant with the head of the bed slightly elevated
- B. Allow the infant to bond with the mother in her room
- C. Offer the infant breastfeeding instead of formula feeding
- D. Wrap the infant in blankets and place in a crib by the viewing window
Correct answer: A
Rationale: Positioning the infant with the head of the bed elevated helps to prevent aspiration and manage secretions until further treatment can be provided. Choice B is incorrect as the priority is ensuring the infant's safety and health, not immediate bonding. Choice C is incorrect as breastfeeding may worsen the condition. Choice D is incorrect as it does not address the potential risk of aspiration associated with esophageal atresia/tracheoesophageal fistula.
3. The educator is teaching about the process of physical growth and development. Which of these describes the directional pattern from head to tail?
- A. Cephalodistal
- B. Cephalocaudal
- C. Proximodistal
- D. Proximocaudal
Correct answer: B
Rationale: Cephalocaudal development is the correct term that describes the directional pattern of growth from head to tail. This means that the head and upper body parts develop before the lower parts. Choice A, 'Cephalodistal,' refers to growth from the center of the body outward, not head to tail. Choice C, 'Proximodistal,' describes growth from the center of the body towards the extremities, not specifically from head to tail. Choice D, 'Proximocaudal,' is not a recognized term in the context of physical growth and development.
4. The nurse is caring for a child with Meckel diverticulum. What type of stool does the nurse expect to observe?
- A. Steatorrhea
- B. Clay-colored
- C. Currant jelly-like
- D. Loose stools with undigested food
Correct answer: C
Rationale: Corrected Rationale: Currant jelly-like stools, which contain blood and mucus, are characteristic of Meckel diverticulum. This symptom occurs due to the bleeding from the ectopic gastric mucosa present in the diverticulum. Steatorrhea (choice A) is not typically associated with Meckel diverticulum. Clay-colored stools (choice B) are seen in conditions affecting the biliary system. Loose stools with undigested food (choice D) may indicate malabsorption issues, but it is not specifically linked to Meckel diverticulum.
5. The nurse's approach when introducing hospital equipment to a preschooler who seems afraid should be based on which principle?
- A. The child may think the equipment is alive.
- B. Explaining the equipment will only increase the child’s fear
- C. One brief explanation will be enough to reduce the child’s fear
- D. The child is too young to understand what the equipment does
Correct answer: A
Rationale: Preschoolers may engage in magical thinking and believe inanimate objects are alive, so the nurse should explain the equipment in a way that reduces fear.
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