ATI RN
Introduction to Maternity and Pediatric Nursing Test Bank Questions
Question 1 of 5
The nurse is taking care of a 2-year-old child with a macule skin lesion. Which clinical finding should the nurse expect to assess with this type of lesion?
Correct Answer: A
Rationale: A macule is a flat, nonpalpable, and discolored area on the skin that is less than 1 cm in diameter. This type of skin lesion is typically characterized by a change in color without any change in texture or thickness of the skin. The clinical finding associated with a macule is a flat, nonpalpable lesion that is smaller in size (less than 1 cm) and regularly shaped. Therefore, the nurse should expect to assess a flat, nonpalpable, and irregularly shaped lesion that is greater than 1 cm in diameter with a different type of skin lesion, not a macule.
Question 2 of 5
Parents report that they have been giving a multivitamin to their 1-year-old infant. The nurse counsels the parents that which vitamin can cause a toxic reaction at a low dose?
Correct Answer: C
Rationale: Vitamin D is a fat-soluble vitamin that can be toxic in high doses, leading to hypercalcemia. Infants are particularly vulnerable to vitamin D toxicity because they have a lower ability to excrete excess vitamin D. Symptoms of vitamin D toxicity include nausea, vomiting, weakness, and kidney problems. Therefore, it is important for parents to avoid giving high doses of vitamin D to infants and always follow healthcare provider recommendations for supplementation.
Question 3 of 5
An infant has been diagnosed with cow's milk allergy. What are the clinical manifestations the nurse expects to assess? (Select all that apply.)
Correct Answer: B
Rationale: In this scenario, the correct answer is B) Vomiting. When an infant has a cow's milk allergy, one of the common clinical manifestations is gastrointestinal symptoms such as vomiting. This occurs due to the body's immune response to the proteins in cow's milk. Option A) Pink mucous membranes is incorrect because it is not typically associated with cow's milk allergy. This symptom is more commonly seen in conditions like dehydration or respiratory distress. Option C) Rhinitis, and Option D) Abdominal pain are also incorrect for this question. Rhinitis (inflammation of the mucous membrane in the nose) and abdominal pain are not primary manifestations of cow's milk allergy in infants. Educationally, understanding the clinical manifestations of cow's milk allergy is crucial for nurses caring for infants. By recognizing these signs, nurses can facilitate early diagnosis and appropriate management to ensure the well-being of the child. It is essential for nurses in maternity and pediatric settings to be knowledgeable about common allergies and their presentations to provide safe and effective care to their patients.
Question 4 of 5
Which intervention should the nurse implement to maintain the skin integrity of the preterm newborn?
Correct Answer: B
Rationale: Preterm newborns have delicate skin that is more susceptible to damage and irritation. Using a neutral pH solution for cleansing helps to maintain the skin's natural acidity and prevent disruption of the skin barrier. It is important to avoid over-bathing or using harsh alkaline-based soaps that can strip the skin of its natural oils and cause dryness or irritation. Cleansing the skin only when necessary helps to protect the fragile skin of preterm newborns and reduce the risk of skin breakdown or injury.
Question 5 of 5
When should the nurse expect jaundice to be present in a newborn with hemolytic disease?
Correct Answer: D
Rationale: In a newborn with hemolytic disease, jaundice typically appears 48 to 72 hours after birth due to the accumulation of bilirubin in the baby's blood. This condition is known as hyperbilirubinemia, which occurs when the liver is still immature and unable to effectively process bilirubin. The breakdown of red blood cells in hemolytic disease leads to an increased production of bilirubin, resulting in jaundice. It is important for healthcare providers to monitor the newborn closely during this time period to ensure appropriate management of the jaundice.