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?
- A. The area is called the anterior fontanel (fontanelle) and typically closes anytime up to 18 months of age.
- B. The area is called a fontanel (fontanelle). They remain open to allow for rapid brain growth in the first months of life.
- C. The soft spots may stay open until your infant is 2 or 3 years old.
- D. Soft spots on the infant's head should have closed by now.
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 harm done by teratogens __________.
- A. is straightforward and predictable
- B. is usually apparent at birth
- C. rarely goes beyond physical damage
- D. depends on age at the time of exposure
Correct answer: D
Rationale: The harm done by teratogens depends on the age at the time of exposure. This means that the effects may vary depending on the developmental stage of the fetus when exposed to the teratogen. Teratogens can have different impacts at different stages of pregnancy, leading to a range of potential outcomes in terms of physical and/or cognitive development. Choices A, B, and C are incorrect because the harm caused by teratogens is not straightforward, may not be apparent at birth, and can go beyond physical damage, affecting cognitive development as well.
3. A healthcare professional auscultates a harsh hollow sound over a client's trachea & larynx. Which action should the healthcare professional take first?
- A. Document findings.
- B. Administer O2 therapy.
- C. Position client in high-Fowler's position.
- D. Administer prescribed albuterol.
Correct answer: A
Rationale: The healthcare professional has identified bronchial breath sounds, which are normal findings over the trachea & larynx, characterized by harsh, hollow, tubular, and blowing sounds. The appropriate initial action for the healthcare professional is to document these normal findings. Oxygen therapy, administering albuterol, or repositioning the client is unnecessary as this finding does not indicate a need for intervention.
4. A caregiver is learning about administering digoxin to a toddler. Which statement by the caregiver indicates an understanding of the teaching?
- A. I will mix the medication with a small amount of juice.
- B. I will give the medication with meals.
- C. I will give a second dose if my child vomits.
- D. I will give my child water after giving the medication.
Correct answer: D
Rationale: The correct statement is D because giving the child water after administering digoxin helps ensure the medication is swallowed properly. Mixing the medication with juice (choice A) may affect its absorption. Giving the medication with meals (choice B) may interfere with its effectiveness. Administering a second dose if the child vomits (choice C) is not recommended as it may lead to an overdose.
5. A nurse is reviewing a client's health history and identifies a history of pressure injuries. What intervention should the nurse include in the plan of care?
- A. Reposition the client every 4 hours
- B. Apply a moisture-retentive dressing
- C. Apply a heating pad to the site
- D. Keep the client on bedrest
Correct answer: B
Rationale: The correct intervention for a client with pressure injuries is to apply a moisture-retentive dressing. This type of dressing helps create a moist wound environment, which is conducive to healing. Repositioning the client every 4 hours is important to prevent further pressure injuries, but it is not the primary intervention for existing pressure injuries. Applying a heating pad to the site can increase the risk of tissue damage and is contraindicated for pressure injuries. Keeping the client on bedrest can lead to further complications and delayed healing of pressure injuries.