ATI RN
ATI Nursing Care of Children
1. The nurse is assessing a child's capillary refill time. This can be accomplished by doing what?
- A. Inspect the chest
- B. Auscultate the heart
- C. Palpate the apical pulse
- D. Palpate the nail bed with pressure to produce a slight blanching
Correct answer: D
Rationale: Capillary refill time is assessed by applying pressure to the nail bed and observing how quickly the color returns, indicating peripheral circulation status.
2. What is the appropriate site to administer an intramuscular (IM) vaccine to a newborn?
- A. The dorsal gluteal muscle
- B. The vastus lateralis muscle
- C. The ventral gluteal muscle
- D. The biceps muscle
Correct answer: B
Rationale: The correct site to administer an intramuscular (IM) vaccine to a newborn is the vastus lateralis muscle. For newborns, the vastus lateralis is preferred over the dorsogluteal site because the dorsogluteal site has been associated with low antibody seroconversion rates, indicating a reduced immune response. The vastus lateralis is also recommended for IM injections in newborns, while the deltoid muscle is preferred for older infants and children. The ventral gluteal muscle and the biceps muscle are not appropriate sites for IM injections. Therefore, choice B is the correct answer.
3. During an otoscopic examination on an infant, in which direction is the pinna pulled?
- A. Up and back
- B. Up and forward
- C. Down and back
- D. Down and forward
Correct answer: C
Rationale: For infants, the pinna is pulled down and back to straighten the ear canal and allow proper visualization of the tympanic membrane during otoscopic examination.
4. The nurse is interviewing the mother of an infant. The mother reports, "I had a difficult delivery, and my baby was born prematurely." This information should be recorded under which heading?
- A. History
- B. Present illness
- C. Chief complaint
- D. Review of systems
Correct answer: A
Rationale: The history section of the health record includes details about pregnancy, labor, and delivery, as these factors can have significant implications for the child's health.
5. The Asian parent of a child being seen in the clinic avoids eye contact with the nurse. What is the best explanation for this considering cultural differences?
- A. The parent feels inferior to the nurse
- B. The parent is showing respect for the nurse
- C. The parent is embarrassed to seek health care
- D. The parent feels responsible for her child's illness
Correct answer: B
Rationale: In many Asian cultures, avoiding eye contact is a sign of respect, especially towards authority figures such as healthcare providers.
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