ATI RN
RN Nursing Care of Children 2019 With NGN
1. What is the primary consideration of susceptibility to infections in neonates?
- A. Increased humoral immunity
- B. Overwhelming anti-inflammatory response
- C. Diminished nonspecific and specific immunity
- D. Excessive levels of immunoglobulin A and immunoglobulin M
Correct answer: C
Rationale: The primary consideration of susceptibility to infections in neonates is their diminished nonspecific and specific immunity. Neonates lack the ability to mount a robust immune response, making them vulnerable to infections. Choice A is incorrect because neonates do not have increased humoral immunity; rather, their humoral immunity is diminished. Choice B is incorrect as neonates do not have an overwhelming anti-inflammatory response; instead, their immune responses are generally weakened. Choice D is incorrect because neonates have diminished or absent levels of immunoglobulin A and immunoglobulin M, contributing to their susceptibility to infections.
2. The nurse is taking vital signs on a group of assigned preschool-aged children. Which assessment finding would indicate the need for further action?
- A. Respiratory rate of 20 breaths per minute
- B. Heart rate of 89 beats per minute
- C. Heart rate of 120 beats per minute
- D. Respiratory rate of 24 breaths per minute
Correct answer: C
Rationale: A heart rate of 120 beats per minute is high for a preschool-aged child and may indicate an underlying issue that requires further assessment. A respiratory rate of 20 breaths per minute (choice A) is within the normal range for preschool children. Similarly, a heart rate of 89 beats per minute (choice B) falls within the expected range. A respiratory rate of 24 breaths per minute (choice D) is slightly elevated but may not be as concerning as a heart rate of 120 beats per minute.
3. A mother tells the nurse that she does not want her infant immunized because of the discomfort associated with injections. What should the nurse explain?
- A. This cannot be prevented
- B. Infants do not feel pain as adults do
- C. This is not a good reason for refusing
- D. A topical anesthetic can be applied
Correct answer: D
Rationale: The nurse should explain that a topical anesthetic can be applied to the injection site before the immunization to reduce discomfort.
4. What is the major cause of death for children older than 1 year in the United States?
- A. Heart disease
- B. Childhood cancer
- C. Unintentional injuries
- D. Congenital anomalies
Correct answer: C
Rationale: Unintentional injuries are the leading cause of death among children older than 1 year in the United States.
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.