ATI RN
Introduction to Maternity and Pediatric Nursing Test Bank Questions
Question 1 of 5
During an ophthalmic assessment, which of the ff are the nurses expected to observe carefully? Choose all that apply
Correct Answer: B
Rationale: In an ophthalmic assessment during maternity and pediatric nursing, observing pupil responses is crucial for several reasons. Pupil responses can provide valuable information about the integrity of the cranial nerves, brainstem function, and potential neurological issues. Changes in pupil size, shape, or reactivity can indicate serious conditions like increased intracranial pressure or cranial nerve damage, which are especially important to monitor in pediatric and maternity patients. The other options are important aspects of an ophthalmic assessment but are not as critical as pupil responses in this context. While the level of central vision (option A) is important for overall eye function, it may not provide immediate insights into urgent neurological issues. External eye appearance (option C) and eye movements (option D) are also important for assessing eye health and function but may not be as directly linked to neurological status as pupil responses. Educationally, understanding the significance of pupil responses in an ophthalmic assessment reinforces the connection between ocular health and neurological function. It highlights the importance of thorough assessments in pediatric and maternity patients to detect any subtle changes that may require prompt intervention. By prioritizing pupil responses, nurses can ensure comprehensive care and early detection of potential complications.
Question 2 of 5
When instructing the client diagnosed with hyperparathyroidism about diet, the nurse should stress the importance of which of the following?
Correct Answer: C
Rationale: For clients diagnosed with hyperparathyroidism, it is important to restrict sodium in the diet. High sodium intake can worsen calcium loss from the bones and increase the risk of kidney stones, both of which are concerns for individuals with hyperparathyroidism. Therefore, it is crucial to advise the client to limit their sodium intake to help manage their condition effectively.
Question 3 of 5
When administering spironolactone (Aldactone) to a client who has had a unilateral adrenalectomy, the nurse should instruct the client about which of the following possible adverse effects of the drug?
Correct Answer: C
Rationale: Spironolactone (Aldactone) is a potassium-sparing diuretic and aldosterone antagonist that is commonly used to treat conditions such as hypertension, heart failure, and edema. One of its common side effects is hormonal effects due to its antiandrogenic properties. In women, spironolactone can lead to menstrual irregularities, including amenorrhea (absence of menstrual periods) or breakthrough bleeding. Therefore, in a client who has had a unilateral adrenalectomy (removal of one adrenal gland), which can already disrupt hormonal balance, the nurse should educate the client about the potential for menstrual irregularities when taking spironolactone.
Question 4 of 5
In assisting a physician to perform a thoracentesis to Mr. Sy, how should the nurse postion a patient with pleural effusion of the left lung?
Correct Answer: B
Rationale: In performing a thoracentesis for a patient with pleural effusion of the left lung, the patient should be positioned sitting at the side of the bed with both arms resting on an overbed table. This position allows for better access to the left lung area and helps the patient maintain a comfortable and stable position during the procedure. Sitting position also helps to expand the intercostal spaces, making it easier for the physician to access the pleural fluid. Additionally, having both arms resting on an overbed table helps the patient remain still and reduce the risk of injury during the procedure. Therefore, this position is the most suitable for performing a thoracentesis for a patient with pleural effusion of the left lung.
Question 5 of 5
Which of the following guidekines does not observe surgical asepisi in the operating room?
Correct Answer: A
Rationale: This statement is incorrect and does not observe surgical asepsis in the operating room. In surgical asepsis, it is crucial that sterile articles do not touch other sterile articles or surfaces to prevent contamination. Any contact between sterile items or surfaces can lead to the transfer of microorganisms, compromising the sterility of the environment. Maintaining a sterile field is essential to prevent surgical site infections and ensure the safety of the patient undergoing the procedure.