ATI RN
Nursing Care of Children ATI
1. During the 2-month well-child checkup, the nurse expects the infant to respond to sound in which manner?
- A. Respond to name
- B. React to loud noise with Moro reflex
- C. Turn his or her head to side when sound is at ear level
- D. Locate sound by turning his or her head in a curving arc
Correct answer: B
Rationale: At 2 months, infants typically react to loud noises with the Moro reflex, a startle response that is normal at this stage of development.
2. What is the recommended position for a child with epiglottitis to ease breathing?
- A. Supine
- B. Prone
- C. Tripod
- D. Semi-Fowler’s
Correct answer: C
Rationale: The correct answer is C, 'Tripod.' In children with epiglottitis, the tripod position is recommended to help open the airway and ease breathing. This position involves the child sitting upright, leaning forward, and supporting themselves with their hands on their knees or another surface. This posture helps improve air entry into the lungs by maximizing the space for breathing. Choices A (Supine), B (Prone), and D (Semi-Fowler’s) are incorrect. Placing a child with epiglottitis in the supine position may further obstruct the airway, while the prone position and semi-Fowler’s position do not facilitate optimal air exchange in these cases.
3. A six-year-old child is admitted to the hospital with a diagnosis of urinary tract infection. Which of these factors contribute to urinary tract infections in young children?
- A. Excessive intake of carbonated beverages.
- B. Insufficient water intake to flush the kidneys.
- C. Voiding pattern of 5-6 times a day.
- D. Infrequent voiding which results in urinary stasis.
Correct answer: D
Rationale: Infrequent voiding can lead to urinary stasis, which increases the risk of urinary tract infections by allowing bacteria to multiply in the bladder. Encouraging regular voiding and proper hydration can help prevent UTIs. Choices A, B, and C are incorrect. Excessive intake of carbonated beverages may irritate the bladder but is not a direct cause of UTIs. Insufficient water intake can concentrate urine but does not necessarily lead to infections. A voiding pattern of 5-6 times a day is within the normal range and is not associated with increased UTI risk.
4. The nurse suspects fluid overload in an infant receiving intravenous fluids. What clinical manifestation is suggestive of water intoxication?
- A. Oliguria
- B. Weight loss
- C. Irritability and seizures
- D. Muscle weakness and cardiac dysrhythmias
Correct answer: C
Rationale: Water intoxication can lead to cerebral edema, causing neurological symptoms such as irritability and seizures. Oliguria, weight loss, and muscle weakness are not typical signs of water intoxication.
5. What play activities should the nurse implement to encourage fluid intake for a child? (Select all that apply.)
- A. Have a tea party.
- B. Use a crazy straw.
- C. Cut gelatin into fun shapes.
- D. All of the above
Correct answer: D
Rationale: Encouraging fluid intake can be fun and engaging through activities like having a tea party, using a crazy
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