ATI RN
ATI Nursing Care of Children 2019 B
1. Which condition is most commonly associated with a 'sunset sign' in infants?
- A. Hydrocephalus
- B. Meningitis
- C. Cerebral palsy
- D. Encephalitis
Correct answer: A
Rationale: The 'sunset sign,' characterized by downward-driven eyes, is most commonly associated with hydrocephalus. This condition causes increased intracranial pressure, leading to the eyes appearing to be forced downward. Meningitis (choice B) typically presents with symptoms such as fever, headache, and a stiff neck, but not the 'sunset sign.' Cerebral palsy (choice C) is a group of disorders affecting movement and muscle coordination, not directly related to the 'sunset sign.' Encephalitis (choice D) is inflammation of the brain, which can cause symptoms like fever, headache, and confusion, but not the specific downward eye gaze seen in the 'sunset sign.'
2. According to Piaget, a 6-month-old infant should be in which developmental stage?
- A. Use of reflexes
- B. Primary circular reactions
- C. Secondary circular reactions
- D. Coordination of secondary schemata
Correct answer: C
Rationale: By 6 months, infants are usually in the stage of secondary circular reactions, where they start to intentionally repeat actions that bring pleasure or interesting results.
3. Why does the nurse have a 2-year-old boy sit in a “tailor” position while palpating for the presence of the testes?
- A. It prevents the cremasteric reflex
- B. Undescended testes can be palpated
- C. The child has an inguinal hernia
- D. The child does not yet have a need for privacy
Correct answer: A
Rationale: The tailor position stretches the muscle responsible for the cremasteric reflex, preventing it from contracting and pulling the testes into the pelvic cavity. This position helps accurately palpate the testes. Choice B is incorrect because the position does not facilitate the palpation of undescended testes specifically. Choice C is incorrect as it does not relate to the rationale behind the tailor position. Choice D is incorrect as the reason for using the tailor position is not related to the child's need for privacy.
4. A major reason for the development of respiratory distress syndrome in the preterm infant is:
- A. Excessive surfactant
- B. Lack of surfactant
- C. Immature immune system
- D. Lack of body fat
Correct answer: B
Rationale: The correct answer is B: Lack of surfactant. Respiratory distress syndrome (RDS) in preterm infants is primarily due to a lack of surfactant, which is crucial for keeping the lungs inflated. Without adequate surfactant, the alveoli collapse, leading to breathing difficulties. Choice A, Excessive surfactant, is incorrect as RDS is caused by an insufficient amount of surfactant. Choice C, Immature immune system, and Choice D, Lack of body fat, are not directly related to the development of respiratory distress syndrome in preterm infants.
5. Rectal temperatures are indicated in which situation?
- A. In the newborn period
- B. Whenever accuracy is essential
- C. Rectal temperatures are never indicated
- D. When rapid temperature changes are occurring
Correct answer: B
Rationale: Rectal temperatures provide the most accurate measurement of core body temperature and are therefore indicated when accuracy is essential.
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