which assessment finding would necessitate action by the nurse for a 10 month old child who is 4 hours postoperative for the placement of a urethral s
Logo

Nursing Elites

ATI RN

RN Pediatric Nursing 2023 ATI

1. Which assessment finding would necessitate action by the nurse for a 10-month-old child who is 4 hours postoperative for the placement of a urethral stent?

Correct answer: B

Rationale: In a postoperative scenario after the placement of a urethral stent, monitoring the child's voiding frequency is crucial. Having only one void since returning from surgery could indicate potential issues like urinary retention, which necessitates prompt nursing intervention to prevent complications.

2. Which principle does not follow neuromaturational theory?

Correct answer: B

Rationale: Neuromaturational theory emphasizes that motor development progresses in a predictable sequence and rate, starting from primitive reflexes to voluntary control. It also states that low-level skills are foundational for higher-level skills. However, the theory does not support the idea that movement solely emerges from an interaction and cooperation of many systems, as it focuses more on the hierarchical development of motor skills.

3. Which statement most reflects the observation that the infant sleeps soundly, awakens on his own, and maintains a quiet alert state?

Correct answer: C

Rationale: A quiet alert state in infants indicates positive neurological development. It showcases the infant's ability to regulate sleep-wake cycles and maintain an optimal state for learning and interaction. Therefore, observing an infant who sleeps soundly, awakens on his own, and stays in a quiet alert state is a reassuring sign of neurological gains and healthy development. Choice A is incorrect as it misinterprets normal behavior as atypical. Choice B is incorrect as it suggests the infant should be on high alert, which is not developmentally appropriate. Choice D is incorrect as it falsely blames the family for disrupting the child's sleep patterns, whereas the scenario described indicates positive neurological growth.

4. A patient in the emergency department reports taking sildenafil (Viagra) and nitroglycerin 1 hr before sexual activity. Which finding should the nurse immediately report to the physician?

Correct answer: D

Rationale: The correct answer is D: BP of 70/50. When sildenafil (Viagra) is taken with nitroglycerin, it can cause severe hypotension that is unresponsive to treatment. The combination of these medications can lead to a dangerous drop in blood pressure. It is crucial to immediately report hypotension in this scenario as it poses a significant risk to the patient's life. It is recommended to allow at least 24 hours to elapse between the last dose of sildenafil and nitroglycerin to prevent such adverse effects. The other vital signs and lab values may be abnormal but do not have the immediate life-threatening implications that severe hypotension does in this context.

5. A patient develops hypotension, laryngeal edema, and bronchospasm after eating peanuts. Which medication should the nurse prepare to administer?

Correct answer: B

Rationale: The patient is exhibiting symptoms of anaphylaxis triggered by a peanut allergy, a severe and potentially life-threatening allergic reaction. The appropriate medication for anaphylaxis is epinephrine. Epinephrine acts quickly to reverse the symptoms by constricting blood vessels, relaxing bronchial muscles, and reducing laryngeal edema, making it the drug of choice for this situation. Promethazine, diphenhydramine, and hydroxyzine are not the first-line treatments for anaphylaxis. Promethazine is an antihistamine with sedative effects, Diphenhydramine is an antihistamine, and Hydroxyzine is also an antihistamine with sedative properties. While these medications can help with mild allergic reactions, they are not as effective or fast-acting as epinephrine in treating the severe manifestations of anaphylaxis.

Similar Questions

In the morning, a healthcare professional receives change-of-shift report on four pediatric clients, each of whom has some form of fluid-volume excess. Which of the children should the healthcare professional see first?
An adolescent client reports recurrent abdominal pain with diarrhea and bloody stools. Which type of inflammatory bowel disease does the nurse suspect based on these data?
The healthcare provider should question an order for glucocorticoids in the treatment of a patient with what condition?
Which parental statement at the end of a teaching session by the nurse indicates correct understanding of colostomy stoma care for the infant client?
Which statement made by a parent of a child with nephrotic syndrome indicates an understanding of discharge teaching?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses