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. The mother of a 6-month-old infant has returned to work and is expressing breast milk to be frozen. She asks for directions on how to safely thaw the breast milk in the microwave. What should the nurse recommend?
- A. Heat only 10 oz or more.
- B. Do not thaw or heat breast milk in a microwave oven.
- C. Always leave the bottle top uncovered to allow heat to escape.
- D. Shake the bottle vigorously for at least 30 seconds after heating.
Correct answer: B
Rationale: Thawing or heating breast milk in a microwave is not recommended because it can create hot spots that may burn the infant and destroy essential nutrients.
3. A hospitalized child with minimal change nephrotic syndrome is receiving high doses of prednisone. What nursing goal is appropriate for this child?
- A. Stimulate appetite
- B. Detect evidence of edema
- C. Minimize risk of infection
- D. Promote adherence to the antibiotic regimen
Correct answer: C
Rationale: Prednisone, an immunosuppressant, increases the child's susceptibility to infections, making infection prevention a critical nursing goal. Detecting edema and stimulating appetite are important but secondary to preventing potentially life-threatening infections.
4. Which clinical manifestations should the nurse expect in a child diagnosed with nephroblastoma?
- A. Atrial fibrillation
- B. Endocarditis
- C. Hyperlipidemia
- D. Hypertension
Correct answer: D
Rationale: The correct answer is D: Hypertension. Nephroblastoma, also known as Wilms' tumor, often causes hypertension due to its impact on the kidney, which plays a role in regulating blood pressure. Atrial fibrillation (choice A) and endocarditis (choice B) are not typically associated with nephroblastoma. Hyperlipidemia (choice C) is also not a common clinical manifestation of nephroblastoma.
5. The nurse is teaching a group of new nursing graduates about identifiable qualities of strong families that help them function effectively. Which quality should be included in the teaching?
- A. Lack of congruence among family members
- B. Clear set of family values, rules, and beliefs
- C. Adoption of one coping strategy that always promotes positive functioning in dealing with life events
- D. Sense of commitment toward growth of individual family members as opposed to that of the family unit
Correct answer: B
Rationale: Strong families have a clear set of values, rules, and beliefs that guide their interactions and help them function effectively as a unit.
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