ATI RN
Maternal Newborn Nursing Questions
Question 1 of 5
What findings would make the nurse suspicious of anorexia in a client?
Correct Answer: B
Rationale: In maternal newborn nursing, it is essential for nurses to be vigilant about signs of anorexia in clients to provide appropriate care and support. The correct answer is B) Significant weight loss and amenorrhea. Anorexia nervosa is characterized by a distorted body image, fear of gaining weight, and restrictive eating habits leading to significant weight loss. Amenorrhea, the absence of menstruation, is a common symptom due to the body conserving energy for survival rather than reproductive functions. Option A) Aversion to exercise and food allergies do not directly correlate with anorexia. While individuals with anorexia may avoid exercise, it is not a defining characteristic. Food allergies are unrelated to anorexia. Option C) Respiratory distress and thick oral mucus are not typical indicators of anorexia. These symptoms may be seen in respiratory conditions or dehydration but are not specific to anorexia. Option D) Cardiac arrhythmias and anasarca are severe complications of prolonged malnutrition in anorexia but are not initial findings that would make a nurse suspicious of the disorder. These occur in advanced stages and require immediate medical attention. Educationally, understanding the signs and symptoms of anorexia in maternal newborn nursing is crucial for early detection and intervention. By recognizing the subtle clues like significant weight loss and amenorrhea, nurses can initiate appropriate care, provide referrals for psychological support, and prevent further complications for both the mother and newborn.
Question 2 of 5
What intervention is highest priority for a woman entering the emergency department after a stranger rape?
Correct Answer: A
Rationale: In the scenario of a woman entering the emergency department after a stranger rape, creating a safe environment is the highest priority intervention. This is crucial for ensuring the immediate physical and emotional well-being of the survivor. By creating a safe space, healthcare providers can help reduce further trauma and promote a sense of security and trust, which is essential for effective patient care and recovery. Offering postcoital contraceptive therapy and providing sexually transmitted disease (STD) prophylaxis are important interventions as well, but they are secondary to creating a safe environment. These interventions focus on preventing potential consequences of the assault. However, in the immediate aftermath of a traumatic event like rape, prioritizing the survivor's safety, comfort, and emotional needs is critical. Taking a thorough health history, while important for comprehensive care and follow-up, is not the highest priority in this situation. The immediate focus should be on addressing the survivor's acute physical and emotional needs. Educators should stress the significance of trauma-informed care, empathy, and prioritizing survivor-centered interventions in cases of sexual assault to provide effective and compassionate care to survivors.
Question 3 of 5
What should the nurse consider when caring for a client who identifies as a lesbian?
Correct Answer: C
Rationale: The correct answer is C) Lesbian women should be tested for cervical cancer every three to seven years. This is because all individuals with a cervix, regardless of sexual orientation, are at risk for cervical cancer due to human papillomavirus (HPV) infection. Regular cervical cancer screening is essential for early detection and treatment. Option A is incorrect because sexual activity is not determined by sexual orientation, and assumptions about sexual behavior can be harmful and perpetuate stereotypes. Option B is incorrect because lesbian women, like all individuals, should be routinely screened for domestic violence as it can affect anyone regardless of sexual orientation. Option D is incorrect because sexual orientation does not determine the risk for bacterial vaginosis; it is influenced by various factors such as sexual practices and vaginal microbiota. In an educational context, it is crucial for nurses to provide culturally competent care to all clients, including those who identify as lesbian. This involves understanding and addressing their unique health needs without making assumptions or judgments based on sexual orientation. Nurses should create a safe and inclusive environment for all clients to ensure they receive appropriate care and support.
Question 4 of 5
What actions should the nurse advise women to take when educating them on breast self-examination (BSE)?
Correct Answer: A
Rationale: In educating women on breast self-examination (BSE), advising them to use the fingertips of their index, middle, and ring fingers (Option A) is essential for several reasons. First, using these fingers allows for better tactile sensitivity to detect any abnormalities in breast tissue. These finer fingers can detect small lumps or changes more effectively than using the entire hand. Option B, using pressure in two intensities, light and deep, is not the best advice for BSE. Applying pressure in varying intensities can lead to confusion and inconsistency in examining the breasts, potentially missing important findings. Consistency in pressure is key to accurately detecting abnormalities. Option C, looking for dimpling while bending forward from the waist, is not directly related to BSE. Dimpling of the skin can be a sign of advanced breast cancer, but it is not a specific technique used in BSE. Focusing on the proper method of palpation is more crucial for early detection. Option D, feeling for lumps while encircling the breast from nipple outward, is not as effective as using the specific fingers mentioned in Option A. Encircling the breast may lead to missing areas or not applying enough pressure to detect abnormalities thoroughly. In an educational context, it is vital for nurses to teach women the proper technique for BSE to empower them in taking charge of their breast health. By emphasizing the use of specific fingers with the correct technique, women can perform BSE accurately and regularly, increasing the likelihood of early detection of breast changes. This knowledge equips women with a proactive approach to their breast health and can lead to better health outcomes through early intervention.
Question 5 of 5
A nurse is conducting an orientation program for a group of newly hired nurses. As part of the program, the nurse is reviewing the issue of informed consent. The nurse determines that the teaching was effective when the group identifies which situation as a violation of informed consent?
Correct Answer: A
Rationale: In most states, only clients over the age of 18 can legally provide consent for health care. Serving as a witness to the signature process, asking whether the client understands what she is signing, and getting verbal consent over the phone for emergency procedures are all key to informed consent and are not violations.