ATI RN
RN Nursing Care of Children Online Practice 2019 A
1. The parent of a 3-month-old infant is concerned because the infant is not able to sit independently. How should the nurse respond to this parent's concern?
- A. Sitting ability and the age of first tooth eruption are not correlated.
- B. Most infants sit steadily at 4 months.
- C. Most infants sit steadily at 3 months.
- D. Most infants do not sit steadily until 6-8 months.
Correct answer: D
Rationale: The correct answer is D because sitting steadily typically occurs closer to 6-8 months of age, not 3 or 4 months. Choice A is incorrect because sitting ability and the age of first tooth eruption are not related. Choice B and C are incorrect as most infants do not sit steadily at 3 or 4 months, and it is more common for infants to achieve this milestone around 6-8 months.
2. A client in labor is receiving IV Opioid analgesics. Which of the following actions should the nurse take?
- A. Instruct the client to self-ambulate every 2 hours.
- B. Offer oral hygiene every 2 hours.
- C. Anticipate medication administration 2 hours prior to delivery.
- D. Monitor fetal heart rate every 2 hours.
Correct answer: B
Rationale: Offering oral hygiene every 2 hours is essential for a client receiving opioid analgesics to prevent dry mouth, nausea, and vomiting, which are common adverse effects associated with opioid use. This intervention promotes comfort and enhances the client's well-being during labor. Instructing the client to self-ambulate every 2 hours is not appropriate for a client in labor receiving opioid analgesics, as it may be challenging and unnecessary during this time. Anticipating medication administration 2 hours prior to delivery is not necessary as the timing of medication administration should be based on the client's pain level and the duration of action of the opioid. Monitoring fetal heart rate every 2 hours is important during labor, but the priority in this case is to address the client's comfort and well-being by offering oral hygiene.
3. Which Apgar criterion can be more difficult to apply to newborns of all races?
- A. pink color
- B. reflex irritability
- C. limp muscle tone
- D. strong breathing
Correct answer: D
Rationale: Among the Apgar criteria, the pink color (choice A), reflex irritability (choice B), and limp muscle tone (choice C) are relatively easy to assess in newborns of all races. However, the criterion that can be more difficult to apply to newborns of all races is strong breathing (choice D). This is because evaluating the strength of a newborn's breathing can be more subjective and require careful observation. Unlike the other criteria that have more visible and objective indicators, assessing the strength of breathing might vary based on the observer's interpretation, making it more challenging to apply universally.
4. A nurse is teaching a client who has fibromyalgia about strategies that might help reduce her symptoms. What should the nurse include in the client education?
- A. Avoid exercise during flare-ups
- B. Do high impact exercises like running
- C. Establish a regular sleep pattern
- D. Increase calcium and caffeine intake
Correct answer: Establish a regular sleep pattern
Rationale:
5. All of the following are contraindications when giving Immunization except:
- A. BCG Vaccine can be given to a child with AIDS
- B. BCG Vaccine can be given to a child with Hepatitis B
- C. DPT can be given to a child that had convulsion 3 days after being given the first DPT dose
- D. DPT can be given to a child with active convulsion or other neurological disease
Correct answer: B
Rationale: The correct answer is B. BCG vaccine can be given to a child with Hepatitis B, as there is no contraindication for this. Choice A, C, and D all present contraindications for administering immunizations. Choice A is incorrect because giving BCG vaccines to a child with AIDS is a contraindication. Choice C is incorrect as convulsions after the first DPT dose indicate a contraindication to subsequent doses. Choice D is incorrect because active convulsions or other neurological diseases are contraindications to receiving the DPT vaccine.