ATI Nursing Care of Children

Correct Answer: D

Rationale: A vesicle is an elevated, circumscribed lesion filled with serous fluid, typically less than 1 cm in diameter.

Correct Answer: B

Rationale: Opisthotonos with pain on flexion is a sign of possible meningitis or other serious neurological conditions, requiring immediate medical evaluation.

Correct Answer: C

Rationale: Diminished breath sounds in an infant are an abnormal finding and warrant further investigation to rule out conditions like atelectasis or pneumonia.

Correct Answer: B

Rationale: The correct site to administer an intramuscular (IM) vaccine to a newborn is the vastus lateralis muscle. For newborns, the vastus lateralis is preferred over the dorsogluteal site because the dorsogluteal site has been associated with low antibody seroconversion rates, indicating a reduced immune response. The vastus lateralis is also recommended for IM injections in newborns, while the deltoid muscle is preferred for older infants and children. The ventral gluteal muscle and the biceps muscle are not appropriate sites for IM injections. Therefore, choice B is the correct answer.

Correct Answer: B

Rationale: Climbing is a gross motor milestone typically achieved between 2 to 3 years of age. It involves coordination and strength. Jumping in place is usually mastered around 2 years of age. Standing on one foot with help is a skill that emerges around 3 years. Riding a tricycle typically occurs closer to 3 years and involves coordination and balance, which are more refined skills compared to climbing at an earlier age.