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?
- A. The child has recently been exposed to an infectious disease
- B. The child has symptoms of a cold but no fever
- C. The child is having intermittent episodes of diarrhea
- D. The child has a disorder that causes a deficient immune system
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. The nurse is aware that if patients from different cultures are implied to be inferior, the emotional attitude the nurse is displaying is what?
- A. Acculturation
- B. Ethnocentrism
- C. Cultural shock
- D. Cultural sensitivity
Correct answer: B
Rationale: Ethnocentrism is the belief that one's own culture is superior to others, which can lead to bias and a lack of cultural competence in healthcare.
3. Pretending a sheet is a cape to mimic a superhero is characteristic of which childhood phenomenon?
- A. Artificialism
- B. Symbolic functioning
- C. Critical thinking
- D. Dramatic play
Correct answer: B
Rationale: The correct answer is B, symbolic functioning. Symbolic functioning refers to children using objects, actions, or ideas to represent other objects, actions, or ideas. In this scenario, pretending a sheet is a cape to mimic a superhero demonstrates the child's ability to engage in symbolic play. Choice A, artificialism, is incorrect as it refers to the belief that inanimate objects have lifelike qualities. Choice C, critical thinking, does not directly relate to the imaginative play described in the question. Choice D, dramatic play, is close but not as precise as symbolic functioning, which specifically highlights the use of objects to represent something else.
4. A 10-month-old infant is diagnosed with gastroesophageal reflux. An esophageal (pH) probe monitor is ordered. What explanation for the purpose of the esophageal probe should the nurse provide to the parents?
- A. Assist in the passage of formula through the esophagus
- B. Identify the number of reflux episodes that are occurring
- C. Determine the time it takes for the stomach to empty its contents
- D. Monitor the pH within the stomach
Correct answer: B
Rationale: The correct answer is B. The esophageal pH probe is used to identify the frequency and severity of reflux episodes by measuring the pH in the esophagus. Choice A is incorrect because the probe does not assist in the passage of formula through the esophagus. Choice C is incorrect as determining the time it takes for the stomach to empty its contents would require a different procedure. Choice D is incorrect as the esophageal pH probe monitors the pH in the esophagus, not the stomach.
5. What is a priority intervention for an infant with a temporary colostomy for Hirschsprung disease?
- A. Teaching how to irrigate the colostomy
- B. Protecting the skin around the colostomy
- C. Discussing the implications of a colostomy during puberty
- D. Using simple, straightforward language to prepare the child
Correct answer: B
Rationale: Protecting the skin around the colostomy is crucial to prevent irritation and infection, which are common complications in infants with colostomies. Teaching and discussing long-term implications are important but secondary to immediate skin care needs.
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