ATI RN
ATI Nursing Care of Children
1. What is the appropriate site to administer an intramuscular (IM) vaccine to a newborn?
- A. The dorsal gluteal muscle
- B. The vastus lateralis muscle
- C. The ventral gluteal muscle
- D. The biceps muscle
Correct answer: B
Rationale: The correct site to administer an intramuscular (IM) vaccine to a newborn is the vastus lateralis muscle. For newborns, the vastus lateralis is preferred over the dorsogluteal site because the dorsogluteal site has been associated with low antibody seroconversion rates, indicating a reduced immune response. The vastus lateralis is also recommended for IM injections in newborns, while the deltoid muscle is preferred for older infants and children. The ventral gluteal muscle and the biceps muscle are not appropriate sites for IM injections. Therefore, choice B is the correct answer.
2. The nurse notes that a child has lost 3.6 kg (8 lb) after 4 days of hospitalization for acute glomerulonephritis. What is the most likely cause of this weight loss?
- A. Poor appetite
- B. Reduction of edema
- C. Restriction to bed rest
- D. Increased potassium intake
Correct answer: B
Rationale: The weight loss is most likely due to the reduction of edema, as glomerulonephritis often causes fluid retention that resolves with treatment, leading to significant weight loss.
3. 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.
4. What condition is often associated with severe diarrhea?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct answer: A
Rationale: Severe diarrhea can lead to a loss of bicarbonate, resulting in metabolic acidosis. This is a common complication of prolonged or severe diarrhea, especially in children.
5. The nurse is aware that skin turgor best estimates what?
- A. Perfusion
- B. Adequate hydration
- C. Amount of body fat
- D. Amount of anemia
Correct answer: B
Rationale: Skin turgor is a quick and simple way to assess hydration status. Poor skin turgor can indicate dehydration.