the nurse is preparing to administer a measles mumps rubella and varicella mmrv vaccine which is a contraindication associated with administering this
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Nursing Elites

ATI RN

Nursing Care of Children ATI

1. The nurse is preparing to administer a measles, mumps, rubella, and varicella (MMRV) vaccine. Which is a contraindication associated with administering this vaccine?

Correct answer: D

Rationale: A compromised immune system is a contraindication for the MMRV vaccine because it is a live attenuated vaccine and could potentially cause an infection in an immunocompromised child.

2. Which clinical manifestations should the nurse anticipate when assessing a child for hypoglycemia?

Correct answer: D

Rationale: The correct answer is D: 'Shaky feeling and dizziness.' Hypoglycemia in children often presents with symptoms like shakiness, dizziness, sweating, hunger, and irritability. These symptoms occur because the brain and body are deprived of the glucose they need to function properly. Choices A, B, and C are incorrect because lethargy, thirst, nausea, and vomiting are not typically primary manifestations of hypoglycemia in children.

3. The nurse is assessing a child suspected of having pinworms. Which is the most common symptom the nurse expects to assess?

Correct answer: D

Rationale: Intense perianal itching is the most common symptom of pinworm infection, especially at night when the female worms lay their eggs

4. When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet is which?

Correct answer: C

Rationale: A diet rich in vegetables, legumes, and starches can provide sufficient amino acids, particularly when complemented with varied food sources to ensure a balanced intake of essential nutrients.

5. The nurse is caring for a 1-month-old infant diagnosed with Hirschsprung’s disease. Which treatment measure should be included in the plan of care?

Correct answer: B

Rationale: The correct answer is B: Surgical removal of the affected section of bowel. Hirschsprung's disease is a congenital condition where a portion of the large intestine lacks nerve cells, leading to difficulties in passing stool. The definitive treatment for this condition is the surgical removal of the affected section of the bowel. Barium enema (Choice A) may be used for diagnosis but is not a treatment. A high-fiber diet (Choice C) is not effective in managing Hirschsprung's disease. A permanent colostomy (Choice D) is not the initial treatment for this condition in infants.

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