the nurse is assessing a 6 month old infant the parent asks when the soft area in the infants head will go away what is the best response by the nurse
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Nursing Elites

ATI RN

Nursing Care of Children Final ATI

1. The parent asks when the soft area in the infant's head will go away. What is the best response by the nurse?

Correct answer: A

Rationale: The best response by the nurse is A, as the anterior fontanel typically closes between 12-18 months of age, allowing for brain growth during infancy. Choice B is incorrect because it does not provide a specific timeframe for the closure of the fontanel. Choice C is incorrect as it suggests a later closure timeframe than usual. Choice D is incorrect as it states that the soft spots should have closed already, which is inaccurate for a 6-month-old infant.

2. 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?

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.

3. Which muscle is contraindicated for the administration of immunizations in infants and young children?

Correct answer: B

Rationale: The dorsogluteal muscle is contraindicated for immunizations in infants and young children due to the risk of injury to the sciatic nerve. The anterolateral thigh is the preferred site.

4. What is an advantage of the ventrogluteal muscle as an injection site in young children?

Correct answer: B

Rationale: The ventrogluteal site is free of significant nerves and vascular structures, making it a safer choice for intramuscular injections in young children compared to other sites that may be more prone to complications.

5. The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine whether she is sexually active?

Correct answer: A

Rationale: Directly asking the adolescent if she is sexually active is the most straightforward and respectful approach, ensuring privacy and fostering trust.

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