ATI RN
Maternity and Pediatric Nursing 4th Edition Test Bank Questions
Question 1 of 5
A nurse is assessing a 6-month-old infant. The nurse recognizes the posterior fontanel usually closes at which age?
Correct Answer: D
Rationale: The posterior fontanel, located at the back of the infant's head, typically closes between 8 to 10 months of age. During infancy, it is normal for fontanels to gradually close as the bones of the skull develop and fuse together. The closure of fontanels is an important part of the infant's growth and development. It is crucial for healthcare providers to monitor fontanel closure as part of a routine physical assessment to ensure proper skull development and growth in infants.
Question 2 of 5
The child who can transfers object from hand to hand and babbles has achieved the developmental age of
Correct Answer: B
Rationale: Transferring objects and babbling typically occur around 6 months.
Question 3 of 5
A febrile patient's fluid output is in excess of normal because of diaphoresis. The nurse should plan fluid replacement based on the knowledge that insensible losses in an afebrile person are normally not greater than:
Correct Answer: C
Rationale: Insensible losses are the fluid losses that occur without the individual being aware of it, such as through breathing, sweating, and through the skin. In an afebrile person, insensible losses are normally around 600ml per 24 hours. This amount can vary depending on factors such as temperature, humidity, and individual metabolism. When a patient is febrile and experiencing diaphoresis (excessive sweating), the fluid output can increase significantly due to the body's attempts to cool itself down. It is important for the nurse to consider these increased fluid losses when planning fluid replacement for a febrile patient to prevent dehydration.
Question 4 of 5
A client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?
Correct Answer: B
Rationale: Increased urine osmolarity would best support the nursing diagnosis of Deficient fluid volume in a client with hyperglycemia. Hyperglycemia can lead to osmotic diuresis, where the body excretes excessive amounts of water to help eliminate glucose. This results in concentrated urine with a higher osmolarity. A high urine osmolarity indicates that the kidneys are conserving water due to decreased fluid volume in the body, supporting the diagnosis of Deficient fluid volume. The other assessment findings (cool, clammy skin, distended neck veins, serum sodium level) are not specific to the diagnosis of Deficient fluid volume in this context.
Question 5 of 5
A mother requests that her child receive the varicella vaccine at the 9-month checkup. The nurse's best response is:
Correct Answer: B
Rationale: The varicella vaccine is typically not given until the child is 12 months or older.