ATI RN
RN Nursing Care of Children 2019 With NGN
1. What is the most appropriate nursing action when intermittently gavage feeding a preterm infant?
- A. Allow formula to flow by gravity
- B. Avoid allowing the infant to suck on the tube
- C. Insert the tube through the nares instead of the mouth
- D. Apply gentle pressure to the syringe to deliver the formula
Correct answer: A
Rationale: The correct action when intermittently gavage feeding a preterm infant is to allow the formula to flow by gravity. This method helps prevent overfeeding and aspiration, which can occur if the formula is delivered too quickly under pressure. Choice B is incorrect as sucking on the tube can cause complications. Choice C is incorrect as the tube is typically inserted through the mouth. Choice D is incorrect as steady pressure can lead to rapid delivery of the formula, increasing the risk of complications.
2. The nurse is preparing to give acetaminophen (Tylenol) to a child who has a fever. What nursing action is appropriate?
- A. Retake the temperature in 15 minutes after giving the Tylenol.
- B. Place a warm blanket on the child so chilling does not occur.
- C. Check to be sure the Tylenol dose does not exceed 15 mg/kg.
- D. Use cold compresses instead of Tylenol to control the fever.
Correct answer: C
Rationale: Ensuring the dose does not exceed 15 mg/kg is critical to avoid overdose and potential liver damage. Retaking the temperature immediately or using cold compresses is not necessary, and placing a warm blanket could exacerbate the fever.
3. What term is appropriate terminology to use for an infant whose intrauterine growth rate was slowed and whose birth weight falls below the 10th percentile on intrauterine growth charts?
- A. Postterm
- B. Postmature
- C. Low birth weight
- D. Small for gestational age
Correct answer: D
Rationale: The correct answer is D, 'Small for gestational age.' A small for gestational age, or small-for-date, infant is any child whose intrauterine growth rate was slowed and whose birth weight falls below the 10th percentile on intrauterine growth curves. Choices A and B, 'Postterm' and 'Postmature,' refer to infants born after 42 weeks of gestational age regardless of birth weight, and do not specifically address growth rate. Choice C, 'Low birth weight,' refers to infants with a birth weight less than 2500 g (5.5 pounds) regardless of gestational age, which is a different classification compared to being small for gestational age.
4. The nurse is teaching parents about potential causes of colic in infancy. Which should the nurse include in the teaching session?
- A. Overeating
- B. All are applicable
- C. Frequent burping
- D. Parental smoking
Correct answer: B
Rationale: Overeating, swallowing excessive air (leading to frequent burping), and parental smoking are known to contribute to colic in infants. Understimulation is not typically associated with colic.
5. What illnesses does respiratory hygiene and cough etiquette by the Centers for Disease Control and Prevention (CDC) prevent?
- A. HBV, Hib, and pertussis
- B. HSV, influenza, and HBV
- C. RSV, influenza, and adenovirus
- D. RSV, pertussis, and varicella
Correct answer: C
Rationale: The correct answer is C: RSV, influenza, and adenovirus. The CDC recommends respiratory hygiene and etiquette to prevent the transmission of respiratory syncytial virus (RSV), influenza, adenovirus, and other droplet-transmitted unknown viruses. Choices A, B, and D are incorrect because HBV, Hib, pertussis, HSV, and varicella are not typically transmitted via droplets but through other modes of transmission.
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