the nurse is caring for an infant who was born 24 hr ago to a mother who received no prenatal care the infant is a poor feeder but sucks avidly on his
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Nursing Elites

ATI RN

Nursing Care of Children ATI

1. The nurse is caring for an infant who was born 24 hr ago to a mother who received no prenatal care. The infant is a poor feeder but sucks avidly on his hands. Clinical manifestations also include hyperactive reflexes, tremors, sneezing, and a high-pitched shrill cry. What does the nurse consider as a possible diagnosis for this infant?

Correct answer: B

Rationale: In this case, the infant's symptoms are consistent with narcotic withdrawal. Infants exposed to drugs in utero may display withdrawal symptoms starting around 12 to 24 hours post-birth. The presentation often includes hyperactive reflexes, tremors, sneezing, high-pitched shrill cry, poor feeding, and sucking avidly on hands. Signs such as loose stools, tachycardia, fever, projectile vomiting, sneezing, and generalized sweating are common. These symptoms are not indicative of a seizure disorder. Placental insufficiency typically leads to a small-for-gestational-age child, which is not mentioned in the scenario. Meconium aspiration syndrome primarily presents with respiratory distress, not the symptoms described in this case.

2. The nurse is preparing to administer a measles, mumps, rubella, and varicella (MMRV) vaccine. Which is a contraindication associated with administering this vaccine?

Correct answer: D

Rationale: A compromised immune system is a contraindication for the MMRV vaccine because it is a live attenuated vaccine and could potentially cause an infection in an immunocompromised child.

3. Which describe the feelings and behaviors of early preschool children related to divorce? (Select all that apply.)

Correct answer: D

Rationale: Preschool children may exhibit regressive behavior, fear abandonment, and blame themselves for their parents' divorce due to their limited understanding of the situation.

4. The mother of a 3-month-old breastfed infant asks about giving her baby water because it is summer and very warm. What should the nurse tell her?

Correct answer: A

Rationale: Breast milk provides adequate hydration, even in warm weather, so additional fluids like water are not necessary and can interfere with breastfeeding.

5. Which condition is often associated with a "ground-glass" appearance on a chest x-ray in neonates?

Correct answer: B

Rationale: The correct answer is B, Respiratory distress syndrome. Respiratory distress syndrome often presents with a "ground-glass" appearance on a chest x-ray in neonates due to surfactant deficiency. Choice A, Pneumonia, typically appears as patchy infiltrates on chest x-ray. Choice C, Bronchopulmonary dysplasia, is characterized by hyperinflation and fibrosis, not a ground-glass appearance. Choice D, Congenital diaphragmatic hernia, usually shows mediastinal shift and bowel loops in the chest cavity on x-ray, not a ground-glass appearance.

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