ATI RN
RN Nursing Care of Children 2019 With NGN
1. What is an appropriate nursing intervention for a child with minimal change nephrotic syndrome (MCNS) who has scrotal edema?
- A. Place an ice pack on the scrotal area.
- B. Place the child in an upright sitting position.
- C. Elevate the scrotum with a rolled washcloth.
- D. Place a warm moist pack to the scrotal area.
Correct answer: C
Rationale: Elevating the scrotum with a rolled washcloth helps reduce edema by promoting fluid drainage. Ice packs are not recommended due to the risk of frostbite, and warm moist packs are not typically used for this purpose. An upright position does not specifically address the edema.
2. A child with acetaminophen (Tylenol) poisoning has been admitted to the emergency department. What antidote does the nurse anticipate being prescribed?
- A. Carnitine (Carnitor)
- B. Fomepizole (Antizol)
- C. Deferoxamine (Desferal)
- D. N-acetylcysteine (Mucomyst)
Correct answer: D
Rationale: N-acetylcysteine is the specific antidote for acetaminophen poisoning, working by replenishing glutathione and preventing liver damage. The other options are antidotes for different types of poisoning (e.g., Fomepizole for methanol or ethylene glycol poisoning).
3. What is the earliest age at which a satisfactory radial pulse can be taken in children?
- A. 1 year
- B. 2 years
- C. 3 years
- D. 6 years
Correct answer: C
Rationale: A satisfactory radial pulse can typically be taken starting at around 3 years of age, as younger children often have pulses that are too fast and irregular for accurate measurement.
4. Which reflex, present at birth, is elicited by stroking the sole of the infant's foot, resulting in the fanning of the toes?
- A. Babinski
- B. Moro
- C. Sucking
- D. Rooting
Correct answer: A
Rationale: The Babinski reflex is the correct answer. This reflex is characterized by the fanning out of the toes when the sole of the foot is stroked. It is a normal reflex in infants and is typically present at birth, disappearing by around 12 months of age. The Moro reflex, which involves the infant's response to a sudden loss of support or a loud noise, is not related to the fanning of toes. Sucking and rooting reflexes are related to feeding behaviors and are not elicited by stroking the sole of the foot.
5. 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.
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