ATI RN
RN Nursing Care of Children 2019 With NGN
1. Which finding suggests fluid volume deficit in an infant presenting with vomiting and diarrhea for 2 days?
- A. Increased blood pressure
- B. A sunken fontanel
- C. Decreased pulse rate
- D. Low urine specific gravity
Correct answer: B
Rationale: A sunken fontanel is a classic sign of dehydration in infants, indicating a fluid volume deficit. In dehydration, the fontanel sinks due to decreased fluid volume in the body. Increased blood pressure (Choice A) is not typically associated with dehydration in infants. Decreased pulse rate (Choice C) is not a common finding in fluid volume deficit, as the body tries to increase the heart rate to compensate for decreased volume. Low urine specific gravity (Choice D) may be seen in dehydration, but it is not as specific or as easily observable as a sunken fontanel.
2. What is an important consideration in understanding the reactions of parents when their infant is born with physical defects?
- A. Grief lasts until the defects are repaired.
- B. Denial is a common adaptive reaction.
- C. The psychologic reaction is similar to that with the death of an infant.
- D. Reactions of health professionals to the birth of an infant can affect parents’ reactions.
Correct answer: C
Rationale: When a parent's infant is born with physical defects, understanding the psychological reactions is crucial. The reaction is often similar to the grief experienced when facing the death of a child. Parents need to grieve for the loss of the expected child and adapt to the needs of a child with physical defects. The grief process typically involves stages like shock, frustration, and anger, which can last for years. Denial during the shock phase is not maladaptive but can help parents cope initially. Additionally, parents are sensitive to the behavior of health professionals, whose interactions can significantly influence the parents' reactions to the infant. Therefore, recognizing the similarity of the psychological reaction to grief is an important consideration in understanding how parents cope with their infant's physical defects.
3. What is the first step in treating a child with suspected anaphylaxis?
- A. Administer oxygen
- B. Start an IV line
- C. Give epinephrine
- D. Monitor vital signs
Correct answer: C
Rationale: The correct answer is C: Give epinephrine. Administering epinephrine is the first and most critical step in treating anaphylaxis. Epinephrine rapidly reverses the symptoms of anaphylaxis, including airway swelling, hypotension, and shock. Delaying administration can lead to severe complications or death, making it essential in emergency treatment. Choice A, administering oxygen, might be necessary but should not delay the administration of epinephrine. Starting an IV line (Choice B) is important for further treatment but not the initial step. Monitoring vital signs (Choice D) is essential but comes after administering epinephrine to stabilize the child.
4. After teaching a group of nursing students about developmental milestones for children between the ages of 1 and 4 years, the instructor determines that the teaching was successful when the students identify which of the following as a gross motor developmental milestone that occurs between 2 to 3 years of age?
- A. Jumping in place
- B. Climbing
- C. Standing on one foot with help
- D. Riding a tricycle
Correct answer: B
Rationale: Climbing is a gross motor milestone typically achieved between 2 to 3 years of age. It involves coordination and strength. Jumping in place is usually mastered around 2 years of age. Standing on one foot with help is a skill that emerges around 3 years. Riding a tricycle typically occurs closer to 3 years and involves coordination and balance, which are more refined skills compared to climbing at an earlier age.
5. Because children younger than 5 years are egocentric, the nurse should do which when communicating with them?
- A. Focus communication on the child.
- B. Use easy analogies when possible.
- C. Explain experiences of others to the child
- D. Assure the child that communication is private
Correct answer: A
Rationale: Focusing communication directly on the child aligns with their egocentric nature and helps engage them in the conversation.