a nurse is assessing an infant who has intussusception which of the following findings should the nurse expect
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Nursing Elites

ATI RN

ATI Pediatric Proctored Exam 2023

1. During an assessment, an infant is suspected to have intussusception. Which of the following findings should the nurse expect?

Correct answer: A

Rationale: Intussusception is a condition where one segment of the intestine telescopes into another, causing obstruction. The classic presentation includes currant jelly stools, which are a mixture of blood and mucus due to the sloughing of the intestinal mucosa. This finding is a result of the compromised blood supply to the affected area and is a key characteristic associated with intussusception.

2. The patient taking warfarin for prevention of deep vein thrombosis has an INR of 1.2. Which action by the nurse is most appropriate?

Correct answer: D

Rationale: An INR level of 1.2 is below the therapeutic range (2-3) for warfarin therapy. Therefore, the nurse should contact the healthcare provider to discuss the need for an increased dose to achieve the desired therapeutic range and prevent deep vein thrombosis effectively. Administering IV push protamine sulfate is used to reverse the effects of heparin, not warfarin. Continuing with the current prescription without addressing the subtherapeutic INR level may not effectively prevent deep vein thrombosis. Administering Vitamin K is indicated for warfarin overdose leading to excessive anticoagulation, not for a subtherapeutic INR level that is below the target range.

3. A caregiver is providing teaching about car seat use to the mother of a six-month-old infant. Which of the following statements by the mother indicates an understanding of the teaching?

Correct answer: A

Rationale: The correct answer is A. Lower anchors and tethers, known as the LATCH child safety seat system, should be used to secure an infant's car seat in the vehicle. This system provides a safer and more secure way of installing the car seat compared to using the seat belt alone. Using the lower anchors and tethers ensures proper installation and reduces the risk of car seat movement during travel, providing optimal protection for the infant. Choices B, C, and D are incorrect. Choice B is incorrect because the car seat harness should be positioned at or below the baby's shoulders, not above. Choice C is incorrect because the car seat should be positioned at the correct recline angle recommended by the car seat manufacturer, which may not necessarily be 90 degrees. Choice D is incorrect because adding padding like a blanket to the car seat is not recommended as it can interfere with the proper fit and function of the car seat, potentially compromising the safety of the infant.

4. The nurse is expecting the admission of a child with severe isotonic dehydration. Which intravenous fluid prescription does the nurse anticipate for this child?

Correct answer: A

Rationale: Isotonic dehydration requires the administration of normal saline to restore fluid balance.

5. The caregiver is providing care to a pediatric client diagnosed with inflammatory bowel disease, who is prescribed daily prednisone. Which caregiver statement regarding administration of this drug indicates correct understanding of the teaching provided by the healthcare provider?

Correct answer: D

Rationale: The correct answer is D. Prednisone should be administered with meals to reduce gastrointestinal upset. Taking prednisone with food helps to minimize stomach irritation and other gastrointestinal side effects associated with the medication.

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