ATI RN
Nursing Care of Children ATI
1. What is the first sign of puberty in boys?
- A. Enlargement of testes
- B. Decreased levels of testosterone
- C. Voice deepening
- D. Pubic hair
Correct answer: A
Rationale: The first sign of puberty in boys is typically the enlargement of the testes. This is due to the increase in production of testosterone, which leads to physical changes such as growth of the testes. Choice B, decreased levels of testosterone, is incorrect as puberty is marked by an increase in testosterone levels. Choice C, voice deepening, and choice D, pubic hair growth, usually occur later in the puberty process compared to testicular enlargement, making them incorrect answers.
2. What is an approximate method of estimating output for a child who is not toilet trained?
- A. Have parents estimate output.
- B. Weigh diapers after each void.
- C. Place a urine collection device on the child.
- D. Have the child sit on a potty chair 30 minutes after eating.
Correct answer: B
Rationale: Weighing diapers is the most accurate way to estimate urine output in a child who is not toilet trained. This method provides a measurable and reliable estimate of fluid output.
3. A newborn is admitted to the nursery with a complete bilateral cleft lip and palate. The mother refuses to see or hold her infant. What should the nurse do first?
- A. Restate what the physician has told her about plastic surgery
- B. Suggest holding her baby without making eye contact
- C. Encourage and allow the mother to express her feelings
- D. Recognize and allow the mother to express her feelings
Correct answer: D
Rationale: In this situation, the priority is to acknowledge and validate the mother's feelings, creating a supportive environment for her. Option D is correct as it focuses on recognizing and allowing the mother to express her emotions. This approach can help build trust and facilitate communication. Options A and B are incorrect as they do not address the mother's emotional needs and may come across as dismissive. Option C is less appropriate as it only encourages expression without explicitly recognizing the mother's current emotional state.
4. The nurse is caring for a child with an order of Ampicillin 250 mg IV in 30 mL of Normal Saline to infuse over 30 minutes. How many mL/hour should the nurse set the pump?
- A. 60
- B. 30
- C. 120
- D. 15
Correct answer: A
Rationale: The correct setting for the infusion pump should be 60 mL/hour to deliver 30 mL in 30 minutes. To calculate the infusion rate in mL/hour, divide the total volume to be infused (30 mL) by the total time for infusion (30 minutes) and then multiply by 60 to convert minutes to hours. Therefore, 30 mL / 30 minutes * 60 minutes/hour = 60 mL/hour. Choices B, C, and D are incorrect because they do not match the calculation based on the given parameters.
5. The nurse is teaching the family of a child with a long-term central venous access device about signs and symptoms of bacteremia. What finding indicates the presence of bacteremia?
- A. Hypertension
- B. Pain at the entry site
- C. Fever and general malaise
- D. Redness and swelling at the entry site
Correct answer: C
Rationale: Fever and general malaise are systemic signs of bacteremia, indicating that the infection may have spread beyond the local entry site. Localized pain, redness, and swelling are signs of a localized infection but do not necessarily indicate bacteremia.
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