ATI RN
ATI Nursing Care of Children 2019 B
1. The nurse is caring for a child with Meckel diverticulum. What type of stool does the nurse expect to observe?
- A. Steatorrhea
- B. Clay-colored
- C. Currant jelly-like
- D. Loose stools with undigested food
Correct answer: C
Rationale: Corrected Rationale: Currant jelly-like stools, which contain blood and mucus, are characteristic of Meckel diverticulum. This symptom occurs due to the bleeding from the ectopic gastric mucosa present in the diverticulum. Steatorrhea (choice A) is not typically associated with Meckel diverticulum. Clay-colored stools (choice B) are seen in conditions affecting the biliary system. Loose stools with undigested food (choice D) may indicate malabsorption issues, but it is not specifically linked to Meckel diverticulum.
2. In teaching the parent of a newly diagnosed 2-year-old child with pyelonephritis related to vesicoureteral reflux (VUR), the nurse should include which information?
- A. Limit fluids to reduce reflux.
- B. Give cranberry juice twice a day.
- C. Have siblings examined for VUR.
- D. Surgery is indicated to reverse scarring.
Correct answer: C
Rationale: Siblings should be examined for VUR as it can run in families, and early detection can prevent complications. Limiting fluids is not advisable, and cranberry juice is not effective in preventing VUR. Surgery is usually not indicated for scarring reversal.
3. What findings would the nurse consider normal in assessing the anterior fontanel of a neonate?
- A. Closed anterior fontanel
- B. Sunken anterior fontanel
- C. Bulging anterior fontanel
- D. Pulsating anterior fontanel
Correct answer: D
Rationale: The correct answer is D: Pulsating anterior fontanel. The fontanel should feel flat, firm, and well demarcated. Pulsations are frequently visible at the anterior fontanel, which is a normal finding in a neonate. A closed anterior fontanel, as mentioned, is a potential sign of a major abnormality. A sunken or bulging fontanel (when the infant is quiet) may be indicative of distress or a major abnormality. Therefore, options A, B, and C are considered abnormal findings when assessing the anterior fontanel of a neonate.
4. The nurse is performing an otoscopic examination on a child. Which are normal findings the nurse should expect? (Select all that apply.)
- A. All below
- B. A well-defined light reflex
- C. A small, round, concave spot near the center of the drum
- D. The tympanic membrane is a nontransparent grayish color
Correct answer: A
Rationale: A well-defined light reflex, a small concave spot, and a grayish, nontransparent tympanic membrane are normal findings during an otoscopic examination in a child.
5. The charge nurse in the pediatric unit is teaching nursing students about pyloric stenosis. A student asks what causes pyloric stenosis. How should the nurse respond?
- A. One portion of the intestines invaginates or telescopes into another
- B. Hypertrophy of the circular pylorus muscle
- C. Relaxed cardiac sphincter
- D. Absent ganglion cells in the colon
Correct answer: B
Rationale: Pyloric stenosis is caused by the hypertrophy (thickening) of the circular muscle of the pylorus, leading to obstruction. Choice A is incorrect as it describes intussusception, not pyloric stenosis. Choice C is incorrect as a relaxed cardiac sphincter is related to gastroesophageal reflux. Choice D is incorrect as it describes Hirschsprung's disease, not pyloric stenosis.
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