ATI RN
Nursing Care of Children ATI
1. The nurse is preparing to administer a measles, mumps, rubella, and varicella (MMRV) vaccine. Which is a contraindication associated with administering this vaccine?
- A. The child has recently been exposed to an infectious disease
- B. The child has symptoms of a cold but no fever
- C. The child is having intermittent episodes of diarrhea
- D. The child has a disorder that causes a deficient immune system
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.
2. The nurse is caring for a child who had a tonsillectomy. Which clinical manifestation should the nurse observe the child for in the postoperative period?
- A. Arrhythmias
- B. Increased swallowing
- C. Increased blood sugar
- D. Increased urinary output
Correct answer: B
Rationale: Correct Answer: B. Increased swallowing can indicate bleeding at the surgical site, which is a potential complication after tonsillectomy. Choice A, Arrhythmias, are not typically associated with tonsillectomy. Choice C, Increased blood sugar, is not a common clinical manifestation after a tonsillectomy. Choice D, Increased urinary output, is not a typical clinical manifestation to observe for in the postoperative period after a tonsillectomy.
3. What is the most common cause of bronchiolitis in infants?
- A. Adenovirus
- B. Influenza virus
- C. Respiratory syncytial virus
- D. Parainfluenza virus
Correct answer: C
Rationale: The correct answer is C, Respiratory syncytial virus (RSV). RSV is the leading cause of bronchiolitis, a common respiratory condition in infants that results in inflammation of the small airways in the lung. It is highly contagious and can cause severe respiratory distress in young children, particularly those under 2 years old. Choice A, Adenovirus, is not the most common cause of bronchiolitis in infants. Choice B, Influenza virus, may cause respiratory infections but is not the primary cause of bronchiolitis. Choice D, Parainfluenza virus, can cause croup and other upper respiratory infections but is not the main cause of bronchiolitis in infants.
4. An infant is diagnosed with a tracheoesophageal fistula. Which assessment finding should the nurse expect?
- A. Jaundice
- B. Hyperactive bowel sounds
- C. Absence of sucking, vomiting
- D. Coughing, with excessive secretion
Correct answer: D
Rationale: Coughing with excessive secretion is a common sign of tracheoesophageal fistula. In this condition, the connection between the trachea and esophagus allows saliva and food to enter the airways, leading to coughing and excessive secretions. Choice A, jaundice, is not typically associated with tracheoesophageal fistula. Hyperactive bowel sounds (Choice B) are more likely seen in conditions like gastroenteritis. Absence of sucking and vomiting (Choice C) is not a typical finding related to tracheoesophageal fistula.
5. Which pediatric condition is most likely to present with a "whooping" sound during coughing?
- A. Croup
- B. Bronchitis
- C. Pertussis
- D. Asthma
Correct answer: C
Rationale: The correct answer is C: Pertussis. Pertussis, also known as whooping cough, is characterized by a "whooping" sound during coughing episodes. This distinctive sound is due to the rapid intake of air after a series of coughs. Choice A, Croup, typically presents with a barking cough and stridor. Choice B, Bronchitis, is characterized by a productive cough with mucus. Choice D, Asthma, usually presents with wheezing and shortness of breath.
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