ATI RN
Nursing Care of Children ATI
1. The nurse is assessing a 3-day-old breastfed newborn who weighed 3400 g (7 pounds, 8 oz) at birth. The infant’s mother is now concerned because the infant weighs 3147 g (6 pounds, 15 oz). The most appropriate nursing intervention is what?
- A. Recommend supplemental feedings of formula.
- B. Explain that this weight loss is within normal limits.
- C. Assess the child further to determine the cause of excessive weight loss.
- D. Encourage the mother to express breast milk for bottle-feeding the infant.
Correct answer: B
Rationale: A neonate normally loses about 10% of the birth weight by age 3 to 4 days. The birth weight is usually regained by the 10th day of life. In this case, the weight loss from 3400 g to 3147 g is within the expected range. Therefore, the most appropriate action is to explain to the mother that this weight loss is within normal limits. Choice A is incorrect because supplemental feedings of formula are not indicated for this expected weight loss in a breastfed newborn. Choice C is incorrect as there is no evidence to suggest excessive weight loss at this point. Choice D is unnecessary at this stage and may not align with the current situation of normal weight loss post-birth.
2. A client has a prescription for Heparin. Which of the following laboratory tests should be monitored while the client is receiving Heparin?
- A. Prothrombin time (PT)
- B. Complete blood count (CBC)
- C. International normalized ratio (INR)
- D. Activated partial thromboplastin time (aPTT)
Correct answer: D
Rationale: Activated partial thromboplastin time (aPTT) is the correct laboratory test to monitor while a client is receiving Heparin. This test is used to assess the therapeutic levels of heparin in the blood, ensuring that the dose is within the safe and effective range. Monitoring aPTT helps healthcare providers adjust the dosage of Heparin to prevent complications such as bleeding or clotting.
3. The client on clopidogrel (Plavix) should be monitored for which adverse effect?
- A. Bleeding
- B. Hypertension
- C. Tachycardia
- D. Bradycardia
Correct answer: A
Rationale: Correct! Clopidogrel (Plavix) is an antiplatelet medication that helps prevent blood clots. As a side effect, it can increase the risk of bleeding. Monitoring for signs of bleeding, such as easy bruising, blood in urine or stools, or prolonged bleeding from cuts, is crucial. Choices B, C, and D are incorrect as hypertension, tachycardia, and bradycardia are not typically associated with clopidogrel use.
4. Which action demonstrates primary prevention?
- A. Administering immunizations
- B. Teaching healthy lifestyle behaviors
- C. Educating about the importance of regular check-ups
- D. Screening for early signs of disease
Correct answer: A
Rationale: Administering immunizations is a primary prevention strategy aimed at preventing diseases before they occur. By administering immunizations, the nurse helps individuals develop immunity against specific diseases, reducing the likelihood of them getting sick in the first place. This proactive approach aligns with primary prevention efforts to promote health and prevent illnesses.
5. A client who has dumping syndrome following a hemi-colectomy should avoid which of the following foods when receiving nutritional teaching from a nurse?
- A. Rice
- B. Poached eggs
- C. Fresh apples
- D. White bread
Correct answer: C: Fresh apples
Rationale: Fresh apples should be avoided by a client with dumping syndrome following a hemi-colectomy because they are high in fiber and can exacerbate gastrointestinal symptoms such as diarrhea and bloating. Rice and poached eggs are good options as they are easily digestible and less likely to trigger dumping syndrome symptoms. White bread is also preferable over whole grain bread due to its lower fiber content, making it a better choice for individuals with dumping syndrome.