ATI RN Nursing Care of Children Exam Form A | Questions and Answers with Rationale | LATEST, 2020 / 2021

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ATI RN Nursing Care of Children Exam Form A | Questions and Answers with Rationale | LATEST, 2020 / 2021 1. A nurse is assessing a school-age child who has meningitis. Which of the following find... ings is the priority for the nurse to report to the provider? ANS: Petechiae on the lower extremities RATIONALE: The presence of a petechial or purpuric rash on a child who is ill can indicate the presence of meningococcemia. This type of rash indicates the greatest risk of serious rapid complications from sepsis and should be reported immediately to the provider. 2. A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect? ANS: Loud, harsh murmur RATIONALE: The nurse should expect to hear a loud, harsh murmur with a ventricular septal defect due to the left-to-right shunting of blood, which contributes to hypertrophy of the infant's heart muscle. 3. A nurse is creating a plan of care for an infant who has an epidural hematoma from a head injury. Which of the following interventions should the nurse include in the plan? ANS: Implement seizure precautions for the infant. RATIONALE: An infant who has an epidural hematoma is at great risk for seizure activity. Therefore, the nurse should implement seizure precautions for the child. 4. A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney? ANS: Serum creatinine 3.0 mg/dL RATIONALE: Creatinine is a byproduct of protein metabolism and is excreted from the body through the kidneys. An elevated serum creatinine level, therefore, can be an indication that the kidneys are not functioning. The nurse should identify that the adolescent's serum creatinine level is higher than the expected reference range of 0.4 to 1.0 mg/dL for an adolescent and can indicate rejection of the kidney. 5. A nurse in an emergency department is performing an admission assessment on a 2 week-old male newborn. Which of the following findings is the priority for the nurse to report to the provider? ANS: Substernal retractions RATIONALE: When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding to report to the provider is substernal retractions. This finding indicates the newborn is experiencing increased respiratory effort, which could quickly progress to respiratory failure. [Show More]

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