ATI RN
ATI Nursing Care of Children
1. What interventions should be implemented to maintain the skin integrity of a preterm infant born at 30 weeks?
- A. Avoid cleaning the skin
- B. Bathe the infant with sterile water
- C. Cleanse the skin with a gentle alkaline-based soap and water
- D. Thoroughly rinse the skin with plain water after bathing
Correct answer: B
Rationale: The correct intervention to maintain the skin integrity of a preterm infant born at 30 weeks is to bathe the infant with sterile water. Bathing with sterile water or a neutral pH solution is recommended to protect the delicate skin of preterm infants, which is more permeable and prone to damage. Choices A, C, and D are incorrect as avoiding cleaning the skin may lead to hygiene issues, cleansing with alkaline-based soap can be harsh on the delicate skin, and thoroughly rinsing with plain water after bathing may not be as gentle and protective for preterm infants.
2. An infant with short bowel syndrome will be on total parenteral nutrition (TPN) for an extended period of time. What should the nurse monitor the infant for?
- A. Central venous catheter infection, electrolyte losses, and hyperglycemia
- B. Hypoglycemia, catheter migration, and weight gain
- C. Venous thrombosis, hyperlipidemia, and constipation
- D. Catheter damage, red currant jelly stools, and hypoglycemia
Correct answer: A
Rationale: Infants with short bowel syndrome requiring prolonged total parenteral nutrition (TPN) are susceptible to central venous catheter infections, electrolyte losses, and hyperglycemia. Monitoring for these complications is crucial to prevent serious outcomes. Choices B, C, and D are incorrect because they do not reflect the common complications associated with prolonged TPN in infants.
3. A child with acute glomerulonephritis is in the playroom and experiences blurred vision and a headache. What action should the nurse take?
- A. Check the urine to see if hematuria has increased.
- B. Obtain the child's blood pressure and notify the healthcare provider.
- C. Obtain serum electrolytes and send urinalysis to the laboratory.
- D. Reassure the child and encourage bed rest until the headache improves.
Correct answer: B
Rationale: Blurred vision and headache in a child with acute glomerulonephritis may indicate severe hypertension, which requires immediate assessment and intervention. Blood pressure should be checked, and the healthcare provider notified.
4. The nurse is preparing a presentation on compensated, decompensated, and irreversible shock in children. What clinical manifestations related to decompensated shock should the nurse include? (Select all that apply.)
- A. All below
- B. Oliguria
- C. Confusion
- D. Pale extremities
Correct answer: A
Rationale: Decompensated shock is characterized by signs such as oliguria, confusion, pale extremities, hypotension, and a thready pulse. These indicate that the body is no longer able to maintain adequate circulation to vital organs.
5. The nurse is discussing issues that are important with parents considering a cross-racial adoption. Which statement made by the parents indicates further teaching is needed?
- A. "We will try to preserve the adopted child's racial heritage."
- B. "We are glad we will be getting full medical information when we adopt our child."
- C. "We will make sure to have everyone realize this is our child and a member of the family."
- D. "We understand strangers may make thoughtless comments about our child being different from us."
Correct answer: C
Rationale: The statement about making sure others realize the child is part of the family may indicate a focus on external validation rather than on the child’s needs and identity, suggesting a need for further teaching.