ATI RN
Maternity and Pediatric Nursing 4th Edition Test Bank Questions
Question 1 of 5
A child is to receive a blood transfusion, if an allergic reaction to the blood occurs, the nurse's first intervention should be:
Correct Answer: C
Rationale: In the scenario of a child experiencing an allergic reaction during a blood transfusion, the nurse's first intervention should always be to stop the blood immediately. This is crucial to prevent further complications and adverse reactions in the child. Pausing the transfusion allows for assessment of the allergic reaction's severity, immediate treatment initiation, and alerting the healthcare team for further management. Relieving symptoms with antihistamines or slowing the flow rate would not address the primary concern of stopping the allergen from entering the child's system. Therefore, stopping the blood immediately is the most appropriate and urgent action to take in this situation.
Question 2 of 5
A patient has end-stage dilated cardiomyopathy. He comes to the emergency department with dyspnea. He says he went to bed and awoke with a feeling of suffocation. He says it was frightening. Which of the ff. responses by the nurse is most appropriate?
Correct Answer: C
Rationale: The most appropriate response by the nurse is option C, "Reclining increases fluid returning to the heart, which builds up fluid in the lungs." In a patient with end-stage dilated cardiomyopathy, reclining position can lead to increased fluid return to the heart due to the failing pump function. This can result in fluid backing up in the lungs, causing symptoms such as dyspnea or feeling of suffocation. By explaining this mechanism to the patient, the nurse can provide valuable information about the condition and the reason for the distressing symptoms experienced by the patient. It also highlights the importance of proper positioning to alleviate symptoms and improve the patient's comfort.
Question 3 of 5
Increased intracranial pressure can cause which of the following?
Correct Answer: D
Rationale: Increased intracranial pressure (ICP) can cause a variety of symptoms, including seizures, nausea, and vomiting. When the pressure inside the skull rises, it can put pressure on the brain tissue, leading to changes in normal brain function. Seizures may occur as a result of the altered brain activity. Nausea and vomiting can also be triggered by increased ICP, as the body's natural response to the disturbance in the brain's normal functioning. Therefore, all of the listed options (seizure, nausea, vomiting) can be caused by increased intracranial pressure.
Question 4 of 5
Which term best describes the identification of the distribution and causes of disease, injury, or illness?
Correct Answer: B
Rationale: The term that best describes the identification of the distribution and causes of disease, injury, or illness is the epidemiologic process. Epidemiology is the study of the patterns, causes, and effects of health and disease conditions in populations. Through the epidemiologic process, health professionals can investigate and understand the distribution of diseases, determine risk factors, and develop strategies for prevention and control. Nursing process refers to the systematic method nurses use to provide patient-centered care. Community-based statistics are data collected from a specific community for various purposes. Mortality and morbidity statistics provide information on deaths and disease rates but do not encompass the comprehensive approach of the epidemiologic process in understanding the causes and distribution of diseases.
Question 5 of 5
The mother of a preterm newborn asks the nurse when she can start breastfeeding. The nurse should explain that breastfeeding can be initiated when her newborn:
Correct Answer: D
Rationale: Breastfeeding can be initiated when the newborn has adequate sucking and swallowing reflexes, which usually develop around 34 to 36 weeks gestational age. It is important for the newborn to have the ability to latch onto the breast and suck effectively in order to receive adequate nutrition and establish a good breastfeeding relationship with the mother. Indicating an interest in breastfeeding is important as well, but having the reflexes necessary for successful breastfeeding is a key factor in determining readiness to begin breastfeeding.