ATI PEDS 2019 A: Questions & Answers
A nurse is caring for a school-age child who is receiving cefazolin via
intermittent IV bolus. The child suddenly develops diffuse flushing of the
skin and angioedema. After discontinuing the medication infusion, which of
the following medications should the nurse administer first?
(Ans- Epinephrine. This child is most likely experiencing an anaphylactic
reaction to the cefazolin. According to evidence-based practice, the nurse
should first administer epinephrine to treat the anaphylaxis. Epinephrine is
a beta adrenergic agonist that stimulates the heart, causes vasoconstriction
of blood vessels in the skin and mucous membranes, and triggers
bronchodilation in the lungs.
A nurse is teaching the parent of an infant about ways to prevent sudden
infant death syndrome (SIDS). Which of the following instructions should
the nurse include?
(Ans- give the infant a pacifier
The nurse should inform the parent that protective factors against SIDS
include breastfeeding and the use of a pacifier when the infant is sleeping
A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy.
Which of the following findings should the nurse expect? (Select all that
apply.)
(Ans- -Ankle clonus-Exaggerated stretch reflexes-Contractures. Negative
Babinski reflex is incorrect. The nurse should expect a child who has
spastic cerebral palsy to exhibit a positive Babinski reflex.Ankle clonus is
correct. The nurse should expect a child who has spastic cerebral palsy to
exhibit ankle clonus, which is a rhythmic reflex tremor when the foot is
dorsiflexed.Exaggerated stretch reflexes is correct. The nurse should
expect a child who has spastic cerebral palsy to exhibit spasticity or
exaggerated stretch reflexes.Uncontrollable movements of the face is
incorrect. The nurse should expect a child who has nonspastic (dyskinetic)
cerebral palsy, rather than spastic (pyramidal) cerebral palsy to exhibit
uncontrollable movements of the face and extremities.Contractures is
correct. The nurse should expect a child who has spastic cerebral palsy to
exhibit contractures due to the tightening of the muscles.
The nurse is providing discharge teaching to the parent of a child who is 1
week postoperative following a cleft palate repair. For which of the following
members of the inter professional team should the nurse initiate a referral?
(Ans- speech therapist The nurse should initiate a referral for a speech
therapist for a child who is postoperative following a cleft palate repair. A
child who has a cleft palate will require speech therapy immediately
following the repair to support speech development and future articulation.
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.An infant who has an
epidural hematoma is at great risk for seizure activity. Therefore, the nurse
should implement seizure precautions for the child.
A nurse is preparing an adolescent for a lumbar puncture. Which of the
following actions should the nurse take?
(Ans- apply a topical analgesic cream to the site 1 hr prior to procedure.
The nurse should apply a topical analgesic to the lumbar site 1 hr prior to
the procedure to decrease the adolescent’s pain while the lumbar needle is
inserted.
A nurse is providing teaching to the parent of a school-age child who has a
new prescription for oral nystatin for the treatment of oral candidiasis.
Which of the following instructions should the nurse include?
(Ans- “Shake the medication prior to administration. “The nurse should
instruct the parent to shake the medication prior to administration to
disperse the medication evenly within the suspension.
A nurse in an emergency department is performing a physical 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. 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.
A nurse is receiving change-of-shift report on four children. Which of the
following children should the nurse see first?
(Ans- A school-age child who has sickle cell anemia and reports
decreased vision in the left eye.When using the urgent vs. nonurgent