a nurse is preparing to administer a measles mumps and rubella mmr vaccine to a 15 month old child which of the following findings is a contraindicati
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Nursing Elites

ATI RN

ATI Pediatrics Proctored Exam 2023

1. A healthcare professional is preparing to administer a measles, mumps, and rubella (MMR) vaccine to a 15-month-old child. Which of the following findings is a contraindication to the administration of this vaccine?

Correct answer: B

Rationale: Taking antibiotics is a contraindication to receiving the MMR vaccine because antibiotics can potentially interfere with the effectiveness of the vaccine. It is essential to avoid administering the MMR vaccine while the child is on antibiotics to ensure the vaccine provides the intended protection.

2. A child is being assessed for possible appendicitis with perforation. Which of the following findings should the nurse expect?

Correct answer: D

Rationale: In a child with appendicitis and possible perforation, the nurse should expect bradycardia due to peritoneal irritation. Bradycardia is a common response to peritoneal inflammation or infection, indicating a possible serious complication. Hyperactive bowel sounds, abdominal distension, and hypoactive bowel sounds are more commonly associated with other gastrointestinal conditions and are less likely to be present in a child with appendicitis and perforation. Therefore, the correct answer is bradycardia (D) as it aligns with the expected physiological response in this scenario.

3. A nurse is providing dietary teaching to the parent of a school-age child with cystic fibrosis. Which of the following statements should the nurse make?

Correct answer: A

Rationale: The parent should provide a well-balanced diet that is high in protein and calories for a child with cystic fibrosis. This diet helps meet the child's increased energy requirements. Offering high-protein meals and snacks throughout the day is essential to ensure adequate nutrition and energy intake for children with cystic fibrosis. Choices B, C, and D are incorrect because children with cystic fibrosis actually need a higher fat intake for proper absorption of fat-soluble vitamins, sodium chloride supplementation is not a general recommendation for all children with cystic fibrosis, and carbohydrate needs are usually based on maintaining adequate weight and growth rather than daily activities.

4. A healthcare professional is preparing for the delivery of a newborn with a known diaphragmatic hernia defect. Which equipment should the professional have on hand for the delivery?

Correct answer: D

Rationale: An endotracheal tube is crucial for managing the airway of a newborn with a diaphragmatic hernia. In this condition, there may be respiratory distress due to incomplete development of the diaphragm, allowing abdominal organs to move into the chest cavity and compress the lungs. The endotracheal tube helps in securing the airway and providing respiratory support if needed until definitive treatment can be initiated.

5. A patient is 1 hour postoperative following an open reduction internal fixation of the left tibia. Which of the following actions should the nurse take?

Correct answer: A

Rationale: The correct action for the nurse to take 1 hour postoperative following an open reduction internal fixation of the left tibia is to assess neurovascular status of the extremities every 4 hours. This frequent assessment is crucial to monitor for any signs of complications such as impaired circulation or nerve damage. Monitoring every 4 hours allows for early detection of any issues, enabling timely intervention and prevention of potential complications. Monitoring the patient's pain level every 8 hours (choice B) is not as immediate or essential for postoperative care. Assisting the patient to the bathroom every 2 hours (choice C) may not be necessary if the patient is not ambulatory yet. Keeping the patient's left leg elevated on two pillows (choice D) can be beneficial but is not the priority in the immediate postoperative period compared to assessing neurovascular status.

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