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. A parent calls the hospital nursing hotline and asks, 'My 8-week-old infant cries 8 hours a day, and is hard to console. Is that normal?' What should the nurse's response be to this parent?
- A. No, call your health care provider.
- B. Let me ask you some more questions to see if there are symptoms of colic.
- C. Yes, maybe your infant is just tired.
- D. Yes, infants cry all the time at that age.
Correct answer: B
Rationale: The correct response for the nurse to provide in this situation is to ask more questions to determine if the infant is displaying symptoms of colic. Colic is a common condition in infants that can lead to prolonged crying and fussiness. It is essential to assess for other symptoms before giving advice to the parent. Choices A, C, and D are incorrect because they do not address the possibility of colic or the need for further assessment of the infant's condition.
3. The nurse is caring for a child with a urinary tract infection who is on trimethoprim-sulfamethoxazole (Bactrim). What side effects of this medication should the nurse teach to the parents and the child? (Select all that apply.)
- A. Rash
- B. Urticaria
- C. All are applicable
- D. Photosensitivity
Correct answer: C
Rationale: Trimethoprim-sulfamethoxazole (Bactrim) can cause side effects like rash, urticaria, and photosensitivity. Parents and the child should be educated on these potential side effects to ensure prompt recognition and management.
4. What is the primary consideration of susceptibility to infections in neonates?
- A. Increased humoral immunity
- B. Overwhelming anti-inflammatory response
- C. Diminished nonspecific and specific immunity
- D. Excessive levels of immunoglobulin A and immunoglobulin M
Correct answer: C
Rationale: The primary consideration of susceptibility to infections in neonates is their diminished nonspecific and specific immunity. Neonates lack the ability to mount a robust immune response, making them vulnerable to infections. Choice A is incorrect because neonates do not have increased humoral immunity; rather, their humoral immunity is diminished. Choice B is incorrect as neonates do not have an overwhelming anti-inflammatory response; instead, their immune responses are generally weakened. Choice D is incorrect because neonates have diminished or absent levels of immunoglobulin A and immunoglobulin M, contributing to their susceptibility to infections.
5. What is a common significant side effect of opioid administration?
- A. Euphoria
- B. Diuresis
- C. Constipation
- D. Allergic reactions
Correct answer: C
Rationale: Constipation is one of the most common side effects of opioid administration due to the slowing down of gastrointestinal motility. Opioids affect the bowel movements, leading to constipation. Euphoria, while a possible effect, is less common than constipation. Diuresis is not a typical side effect of opioids; instead, urinary retention may occur. Allergic reactions are rare side effects of opioids, with symptoms such as rash, itching, or anaphylaxis.
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