ATI RN
Nursing Care of Children ATI
1. A 10-month-old infant is diagnosed with gastroesophageal reflux. An esophageal (pH) probe monitor is ordered. What explanation for the purpose of the esophageal probe should the nurse provide to the parents?
- A. Assist in the passage of formula through the esophagus
- B. Identify the number of reflux episodes that are occurring
- C. Determine the time it takes for the stomach to empty its contents
- D. Monitor the pH within the stomach
Correct answer: B
Rationale: The correct answer is B. The esophageal pH probe is used to identify the frequency and severity of reflux episodes by measuring the pH in the esophagus. Choice A is incorrect because the probe does not assist in the passage of formula through the esophagus. Choice C is incorrect as determining the time it takes for the stomach to empty its contents would require a different procedure. Choice D is incorrect as the esophageal pH probe monitors the pH in the esophagus, not the stomach.
2. Which vaccine is contraindicated in a child with a history of severe egg allergy?
- A. MMR
- B. Varicella
- C. Influenza
- D. Hepatitis B
Correct answer: C
Rationale: The correct answer is C: Influenza. The influenza vaccine is produced using egg-based technology, so individuals with a severe egg allergy are at risk of an allergic reaction if vaccinated with the influenza vaccine. This is due to the potential presence of egg proteins in the vaccine. Choices A, B, and D are not contraindicated in children with severe egg allergy. The MMR and Varicella vaccines do not pose a risk for children with egg allergies, and the Hepatitis B vaccine is also safe for these individuals.
3. Which of the following is a characteristic finding in Kawasaki disease?
- A. Strawberry tongue
- B. Polyarthritis
- C. Hematuria
- D. Rashes
Correct answer: A
Rationale: A 'strawberry tongue' is a characteristic finding in Kawasaki disease. The presence of a 'strawberry tongue' is a classic sign of Kawasaki disease, along with other features such as conjunctivitis and rash. Choice B, polyarthritis, is not typically seen in Kawasaki disease. Choice C, hematuria, is not a common finding in Kawasaki disease but may be seen in other conditions. Choice D, rashes, are present in Kawasaki disease but are not as specific or characteristic as the 'strawberry tongue'. Therefore, the correct answer is A.
4. The nurse is assessing a 3-year-old African American child whose height and weight are at the 20th percentile on the growth chart. What should the nurse recognize?
- A. The data suggest the child requires nutritional intervention
- B. The NCHS charts are accurate for U.S. African American children
- C. A correction factor is used for nonwhite ethnic groups
- D. No assessment can be made until several measurements are plotted over time
Correct answer: B
Rationale: The NCHS growth charts serve as reference guides for all racial or ethnic groups, including African American children. The 20th percentile for height and weight does not indicate nutritional failure but provides a reference point for ongoing assessment. Choice A is incorrect because being at the 20th percentile does not automatically imply the need for nutritional intervention. Choice C is incorrect as there is no correction factor specifically used for nonwhite ethnic groups in this context. Choice D is incorrect as a single measurement at the 20th percentile can provide valuable information for assessment.
5. 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.'
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