ATI RN
Maternity and Pediatric Nursing 4th Edition Test Bank Questions
Question 1 of 5
A 40 year-old female nurse had a fecal impaction and was admitted to the hospital. The physician orders an oil retention enema followed by a cleansing enema. What is the rationale for administering the oiul enema first?
Correct Answer: B
Rationale: The rationale for administering the oil retention enema first in this case is to help soften the fecal mass and lubricate the walls of the rectum and colon. This will make it easier for the impacted stool to be passed, reducing the risk of injury or discomfort during the procedure. The oil enema acts as a lubricant, making it easier for the hardened fecal mass to be expelled from the body without causing damage to the intestinal walls. Additionally, the oil enema helps to soften the fecal mass, further aiding in its removal.
Question 2 of 5
Clinical manifestations of Huntington's disease include:
Correct Answer: D
Rationale: Huntington's disease is a progressive neurological disorder that affects movement, cognition, and behavior. The three main clinical manifestations of Huntington's disease are abnormal involuntary movements (chorea), intellectual decline, and emotional disturbances. Chorea is characterized by involuntary jerky movements that are often random and unpredictable. Intellectual decline includes difficulties with cognitive functions such as planning, organizing, and remembering. Emotional disturbances may manifest as irritability, depression, anxiety, or mood swings. Overall, individuals with Huntington's disease experience a wide range of symptoms that impact both their physical and mental well-being.
Question 3 of 5
Four-year-old Brian appears to be upset by hospitalization. Which is an appropriate intervention?
Correct Answer: A
Rationale: Option A, "Let him know it is all right to cry," is the most appropriate intervention for a four-year-old like Brian who appears to be upset by hospitalization. Acknowledging and validating his emotions, including the possibility of crying, is important for his emotional well-being. By letting Brian know it is okay to express his feelings, he can feel supported and understood during a potentially difficult time. It is crucial for children to feel that their emotions are valid and accepted, promoting their emotional resilience and coping skills. This approach fosters trust and comfort, helping Brian navigate his emotions in a healthy way.
Question 4 of 5
A nurse is assessing a newborn infant who was born to a mother who is addicted to drugs. Which of the following assessment findings would the nurse expect to note during the assessment of this newborn?
Correct Answer: C
Rationale: Newborn infants born to mothers who are addicted to drugs are at risk for neonatal abstinence syndrome (NAS) due to drug withdrawal. Lethargy is a common finding in newborns with NAS. This is characterized by excessive sleepiness, decreased responsiveness, and lack of energy or enthusiasm for activities. Lethargy is often seen as a result of the withdrawal symptoms experienced by the newborn due to exposure to drugs in utero. It is important for the nurse to monitor the newborn closely for signs of withdrawal and provide appropriate care and interventions to manage NAS symptoms.
Question 5 of 5
The nurse is examining 12-month-old Amy, who was brought to the clinic for persistent diaper rash. The nurse finds perianal inflammation with satellite lesions that cross the inguinal folds. What is most likely the cause of the diaper rash?
Correct Answer: B
Rationale: The presentation of perianal inflammation with satellite lesions that cross the inguinal folds is highly suggestive of a Candida albicans (yeast) diaper rash. Yeast diaper rash is characterized by redness, swollenness, and usually involves the skin folds. The warm, moist environment created by a diaper provides an ideal setting for Candida albicans to grow and cause a rash. The presence of satellite lesions that cross the inguinal folds further supports the diagnosis of a yeast infection rather than other causes like impetigo, irritation from urine and feces, or infrequent diapering. Treatment for yeast diaper rash typically involves antifungal creams or ointments.