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. What self-report pain rating scales can be used in children as young as 3 years of age?

Correct answer: C

Rationale: The FACES Pain Rating Scale is suitable for children as young as 3 years of age. It uses facial expressions to depict different levels of pain, making it easy for young children to understand and use. The Poker Chip Tool is validated for children aged 4 and older who have a certain level of cognitive ability. The Visual Analog Scale is more appropriate for children aged 7 and above. The Word-Graphic Rating Scale, which uses descriptive words, is recommended for children in the age range of 4 to 17 years.

3. Which developmental milestone would the nurse expect an 11-month-old infant to have achieved?

Correct answer: A

Rationale: The correct answer is A: Sitting independently. By 11 months, most infants can sit independently. This milestone usually precedes walking, which typically occurs closer to 12 months. Turning a doorknob and building a tower of four cubes involve more complex motor skills that are typically achieved later in development. Therefore, at 11 months, sitting independently is the milestone that the nurse would expect an infant to have achieved.

4. Which actions by the nurse demonstrate clinical reasoning? (Select all that apply.)

Correct answer: A

Rationale: Clinical reasoning involves deliberate and thoughtful decision-making, considering alternatives, and using both formal and informal data gathering methods to provide optimum care.

5. Which condition is most commonly associated with a 'sunset sign' in infants?

Correct answer: A

Rationale: The 'sunset sign,' characterized by downward-driven eyes, is most commonly associated with hydrocephalus. This condition causes increased intracranial pressure, leading to the eyes appearing to be forced downward. Meningitis (choice B) typically presents with symptoms such as fever, headache, and a stiff neck, but not the 'sunset sign.' Cerebral palsy (choice C) is a group of disorders affecting movement and muscle coordination, not directly related to the 'sunset sign.' Encephalitis (choice D) is inflammation of the brain, which can cause symptoms like fever, headache, and confusion, but not the specific downward eye gaze seen in the 'sunset sign.'

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