ATI RN
Nursing Care of Children ATI
1. What is characteristic of a neonate’s vision?
- A. Pupils react to light
- B. Tear glands function
- C. Blink reflex is absent
- D. Ciliary muscles are mature
Correct answer: A
Rationale: The correct answer is A: 'Pupils react to light.' Newborns' pupils do react to light, indicating that the visual pathway is functioning. However, a neonate's vision is still developing, and they can only focus on objects close to their face. Choice B is incorrect because tear glands are functional at birth. Choice C is incorrect because the blink reflex is present in neonates and helps protect their eyes. Choice D is incorrect as neonates' ciliary muscles are not fully developed.
2. A 4-month-old infant is discharged home after surgery for the repair of a cleft lip. What should instructions to the parents include?
- A. Provide crib toys for distraction
- B. Breast- or bottle-feeding can begin immediately
- C. Give pain medication to the infant to minimize crying
- D. Leave the infant in the crib at all times to prevent suture strain
Correct answer: C
Rationale: Pain management is essential postoperatively to reduce crying, which could place strain on the surgical site. Feeding and holding the infant are allowed, but care should be taken to avoid placing pressure on the suture line.
3. The parent of a child hospitalized with acute glomerulonephritis asks the nurse why blood pressure readings are being taken so often. What knowledge should influence the nurse's reply?
- A. The antibiotic therapy contributes to labile blood pressure values.
- B. Hypotension leading to sudden shock can develop at any time.
- C. Acute hypertension is a concern that requires monitoring.
- D. Blood pressure fluctuations indicate that the condition has become chronic.
Correct answer: C
Rationale: Acute hypertension is a common complication of acute glomerulonephritis, requiring frequent monitoring to prevent complications such as encephalopathy or heart failure. Blood pressure fluctuations can occur but are not necessarily indicative of chronic disease.
4. In children with Type 1 diabetes, what is a common early sign of hypoglycemia?
- A. Irritability
- B. Rapid heartbeat
- C. Confusion
- D. Sweating
Correct answer: D
Rationale: Sweating is indeed one of the earliest signs of hypoglycemia in children with Type 1 diabetes. When blood sugar levels drop too low, the body releases stress hormones like adrenaline, which can lead to sweating. While irritability, rapid heartbeat, and confusion can also be seen in hypoglycemia, sweating is particularly common as a quick indicator of low blood sugar levels in children with Type 1 diabetes.
5. A school-age child with cancer is being prepared for a procedure. The child says, “I have had one of these before. They hurt.” The nurse bases her response on what knowledge related to pain in this patient?
- A. Often misrepresent experiencing pain
- B. Tolerate pain better than adults
- C. Become accustomed to painful procedures
- D. Commonly experience treatment-related moderate to severe pain when they have cancer
Correct answer: D
Rationale: The correct answer is D. Pain is frequently reported by children with cancer, with around 84% experiencing it. Most children report moderate to severe pain, with about half finding it highly distressing. There is no evidence to suggest that children often misrepresent their pain experiences. Pain tolerance is not solely based on age but is a complex phenomenon. Children do not become accustomed to painful procedures, as each experience of pain is unique.
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