ATI RN
Nursing Care of Children ATI
1. The apnea monitor alarm sounds on a neonate for the third time during this shift. What is the priority action by the nurse?
- A. Provide tactile stimulation.
- B. Administer 100% oxygen.
- C. Investigate possible causes of a false alarm.
- D. Assess infant for color and presence of respirations.
Correct answer: D
Rationale: The priority action for the nurse when the apnea monitor alarm sounds on a neonate is to assess the infant for color and the presence of respirations. This initial assessment helps determine the infant's respiratory status and the need for immediate intervention. Providing tactile stimulation or administering oxygen should only be done after assessing the infant's respiratory status. Investigating possible causes of a false alarm comes after ensuring the infant's well-being through the initial assessment.
2. The nurse is caring for an infant after a cleft lip repair. Which of these measures should be included in the plan of care?
- A. Position prone
- B. Provide fluids from a cup
- C. Position supine
- D. Avoid elbow restraints
Correct answer: C
Rationale: The correct measure that should be included in the plan of care for an infant after a cleft lip repair is to position the infant supine. Placing the infant in a supine position helps protect the surgical site from injury and promotes proper healing. Choice A, 'Position prone,' is incorrect as placing the infant prone can put pressure on the surgical site and hinder healing. Choice B, 'Provide fluids from a cup,' is not directly related to the surgical care of a cleft lip repair. Choice D, 'Avoid elbow restraints,' is not specific to the postoperative care of a cleft lip repair.
3. The parent of a 3-month-old infant is concerned because the infant is not able to sit independently. How should the nurse respond to this parent's concern?
- A. Sitting ability and the age of first tooth eruption are not correlated.
- B. Most infants sit steadily at 4 months.
- C. Most infants sit steadily at 3 months.
- D. Most infants do not sit steadily until 6-8 months.
Correct answer: D
Rationale: The correct answer is D because sitting steadily typically occurs closer to 6-8 months of age, not 3 or 4 months. Choice A is incorrect because sitting ability and the age of first tooth eruption are not related. Choice B and C are incorrect as most infants do not sit steadily at 3 or 4 months, and it is more common for infants to achieve this milestone around 6-8 months.
4. What is most important in the management of cellulitis?
- A. Burow solution compresses
- B. Oral or parenteral antibiotics
- C. Topical application of an antibiotic
- D. Incision and drainage of severe lesions
Correct answer: B
Rationale: Oral or parenteral antibiotics are essential in treating cellulitis to eliminate the infection. Topical antibiotics are not sufficient, and incision and drainage are only for abscesses.
5. What signs or symptoms are most commonly associated with the prodromal phase of acute viral hepatitis?
- A. Bruising and lethargy
- B. Anorexia and malaise
- C. Fatigability and jaundice
- D. Dark urine and pale stools
Correct answer: B
Rationale: The correct answer is B: Anorexia and malaise. The prodromal phase of acute viral hepatitis is characterized by nonspecific symptoms such as anorexia (loss of appetite) and malaise (general feeling of discomfort). These symptoms typically precede the more specific signs of jaundice, dark urine, and pale stools that manifest in the icteric phase. Choices A, C, and D are incorrect because bruising and lethargy, fatigability and jaundice, and dark urine and pale stools are typically seen in later stages of acute viral hepatitis, not in the prodromal phase.
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