ATI RN
Nursing Care of Children Final ATI
1. Which responsibilities are included in the pediatric nurse's promotion of the health and well-being of children? (Select all that apply.)
- A. Promoting disease prevention
- B. Providing financial assistance
- C. Providing support and counseling
- D. A, C
Correct answer: D
Rationale: Pediatric nurses promote health through disease prevention, support, counseling, therapeutic relationships, and participating in ethical decision-making.
2. The nurse is performing an assessment on a 10-week-old infant. The nurse understands that the developmental characteristic of hearing at this age is which?
- A. The infant responds to his own name.
- B. The infant localizes sounds by turning his head directly to the sound.
- C. The infant turns his head to the side when sound is made at the level of the ear.
- D. The infant locates sound by turning his head to the side and then looking up or down.
Correct answer: C
Rationale: By 10 weeks, infants typically turn their heads to the side to locate the source of a sound made at ear level.
3. A health care provider prescribes feedings of 1 to 2 oz Pedialyte every 3 hours and to advance to 1/2 strength Similac with iron as tolerated postoperatively for an infant who had a pyloromyotomy. The nurse should decide to advance the feeding if which occurs?
- A. The infant's IV line has infiltrated.
- B. The infant has not voided since surgery.
- C. The infant's mother states the infant is tolerating the feeding okay.
- D. The infant is taking the Pedialyte without vomiting or distention.
Correct answer: D
Rationale: The decision to advance feedings after a pyloromyotomy is based on the infant's ability to tolerate the current feedings without vomiting or abdominal distention. Ensuring the infant can keep down Pedialyte is the key indicator for moving to the next stage of feeding. Choices A, B, and C are incorrect because they do not directly relate to the infant's ability to tolerate the feeding. An infiltrated IV line, lack of voiding, or the mother's statement do not provide direct information on the infant's tolerance to the feeding, unlike the absence of vomiting and distention.
4. Which of the following is a hallmark sign of intussusception in children?
- A. Bilious vomiting
- B. "Currant jelly" stools
- C. Abdominal distention
- D. Constipation
Correct answer: B
Rationale: "Currant jelly" stools, consisting of mucus and blood, are characteristic of intussusception in children. It occurs due to the telescoping of a segment of the intestine into an adjacent segment, leading to obstruction and subsequent mucosal ischemia, causing the passage of bloody mucus in the stool. Bilious vomiting can be seen in other conditions like bowel obstruction, abdominal distention can be present but is not as specific, and constipation is less likely in the presentation of intussusception.
5. The nurse is preparing to admit a 7-year-old child with Crohn disease. What clinical manifestations should the nurse expect to observe?
- A. Pain is common.
- B. Weight loss is severe.
- C. All are correct.
- D. Diarrhea is moderate to severe.
Correct answer: C
Rationale: The correct answer is C because Crohn's disease commonly presents with pain, severe weight loss, and moderate to severe diarrhea in affected individuals. Therefore, all the manifestations listed are typically observed in patients with Crohn's disease. Choice A alone is not sufficient as weight loss and diarrhea are also prominent symptoms. Choice B is incorrect as it only mentions weight loss, omitting other common manifestations. Choice D is also incorrect as it does not cover the full range of expected clinical signs in Crohn's disease.
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