a child with acute gastrointestinal bleeding is admitted to the hospital the nurse observes which sign or symptom as an early manifestation of shock
Logo

Nursing Elites

ATI RN

ATI Nursing Care of Children 2019 B

1. A child with acute gastrointestinal bleeding is admitted to the hospital. The nurse observes which sign or symptom as an early manifestation of shock?

Correct answer: A

Rationale: Restlessness is an early sign of shock due to decreased perfusion and oxygenation to the brain. This symptom requires immediate attention to prevent the progression to more severe stages of shock. Rapid capillary refill (Choice B) is not typically an early sign of shock but rather a sign of adequate perfusion. Increased temperature (Choice C) may occur in later stages of shock due to the body's response to stress. Increased blood pressure (Choice D) is not an early sign of shock; in fact, blood pressure tends to decrease in shock as a compensatory mechanism.

2. A thorough systemic physical assessment is necessary in the extremely low-birth-weight (ELBW) infant to detect what?

Correct answer: C

Rationale: In extremely low-birth-weight (ELBW) infants, a thorough systemic physical assessment is crucial to detect subtle changes that may indicate an underlying problem. These infants are highly vulnerable and may show signs of stress through changes in feeding behavior, activity, color, oxygen saturation, or vital signs. Monitoring weight in ELBW infants primarily reflects genitourinary function rather than fluid retention. Difficulties in maternal-child attachment are important but are usually assessed during parental visits and are not the primary focus of a systemic physical assessment. Changes in the Apgar score are used immediately after birth to assess the transition to extrauterine life and are not as relevant in the following 24 hours to detect ongoing subtle issues.

3. Which nonpharmacologic intervention appears to be effective in decreasing neonatal procedural pain?

Correct answer: D

Rationale: Oral sucrose and nonnutritive sucking are effective nonpharmacologic interventions for reducing procedural pain in neonates.

4. The nurse is preparing to admit a 5-year-old child with hepatitis A. What clinical features of hepatitis A should the nurse recognize?

Correct answer: C

Rationale: The correct answer is C. Hepatitis A typically presents with a rapid onset, early fever, and nausea/vomiting. These are common clinical features seen in patients with hepatitis A. A pruritic rash is not commonly associated with hepatitis A, so choice C is incorrect. Choice A and B alone are not sufficient to cover all the clinical features of hepatitis A.

5. 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?

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.

Similar Questions

The parent of an infant with colic tells the nurse, "All this baby does is scream at me; it is a constant worry." What is the nurse's best action?
The nurse is caring for an adolescent hospitalized for asthma. The adolescent belongs to a large family. The nurse recognizes that the adolescent is likely to relate to which group?
At which age should the nurse expect most infants to begin to say mama and dada with meaning?
A teenager is accompanied by his mother to the annual physical examination. The nurse is aware of privacy issues related to the teenager. While the mother is in the room, which topic should the nurse avoid?
The nurse on a pediatric unit is writing guidelines for age-specific preparation of children for procedures based on developmental characteristics. What guideline is accurate?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses