ATI RN
Foundations and Adult Health Nursing Study Guide Answers Questions
Question 1 of 5
If Baby Sharon develops dehydration, what is the FIRST sign to look for by Nurse Juvy?
Correct Answer: B
Rationale: Sunken fontanels are one of the earliest signs of dehydration in infants. Fontanels are soft spots on an infant's head where the skull bones have not yet fused together. If a baby's fontanel appears sunken, it indicates that the baby is likely dehydrated. This occurs because when there is a lack of fluid in the body, the soft spots on the head will appear depressed or sunken. It is crucial for Nurse Juvy to closely monitor the fontanels of Baby Sharon, as identifying dehydration early is essential for prompt intervention and preventing complications.
Question 2 of 5
Before finishing the check up, which of the following principles is NOT included among the principles of guidance in handling Richard?
Correct Answer: D
Rationale: The principles of guidance in handling Richard involve understanding and addressing the behaviors and needs of the child, such as controlling temper tantrums, basing expectations within the child's limitations, and acceptance of certain behaviors like masturbation as normal but to be discouraged in public. However, reinforcing the correct use of language is not typically included as a principle specifically in handling Richard. Therefore, this choice is NOT included among the principles of guidance in this context.
Question 3 of 5
During surgery, the nurse observes an unusual odor emanating from the surgical site. What should the nurse do?
Correct Answer: C
Rationale: If the nurse observes an unusual odor emanating from the surgical site during surgery, it is important to inform the surgeon immediately and assess for signs of infection. Changes in odor can sometimes be an early sign of infection, which requires prompt attention and intervention. By communicating with the surgeon and conducting a thorough assessment, the nurse can help ensure the timely detection and management of any potential complications, such as infection, that may be affecting the patient's surgical outcome. Prompt action in response to unusual observations is crucial to maintaining patient safety and well-being during surgical procedures.
Question 4 of 5
If Baby Sharon develops dehydration, what is the FIRST sign to look for by Nurse Juvy?
Correct Answer: B
Rationale: Sunken fontanels are one of the earliest signs of dehydration in infants. Fontanels are soft spots on an infant's head where the skull bones have not yet fused together. If a baby's fontanel appears sunken, it indicates that the baby is likely dehydrated. This occurs because when there is a lack of fluid in the body, the soft spots on the head will appear depressed or sunken. It is crucial for Nurse Juvy to closely monitor the fontanels of Baby Sharon, as identifying dehydration early is essential for prompt intervention and preventing complications.
Question 5 of 5
A woman in active labor is diagnosed with uterine rupture. What is the priority nursing action?
Correct Answer: A
Rationale: The priority nursing action for a woman diagnosed with uterine rupture during labor is to prepare for immediate cesarean section. Uterine rupture is a serious obstetric emergency that can lead to severe maternal and fetal complications, including hemorrhage, fetal distress, and injury to both mother and baby. A cesarean section is necessary to deliver the baby promptly and address any potential complications, such as controlling bleeding and ensuring the safety of both the mother and the baby. Time is critical in these situations, and prompt surgical intervention is essential to optimize outcomes. Administering intravenous oxytocin or assisting the mother into a hands-and-knees position would not address the immediate risks associated with uterine rupture. Initiating cardiopulmonary resuscitation (CPR) is only necessary if the mother's condition deteriorates to the point of cardiac or respiratory arrest, which may occur as a result of significant hemorrhage or other complications associated with uterine
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