ATI RN
Maternal Disorders Questions
Question 1 of 5
What nursing action will the nurse implement after feeding an infant with hydrocephalus?
Correct Answer: C
Rationale: The correct answer is C: Leave the infant in a side-lying position. This is important for infants with hydrocephalus as it helps prevent aspiration and reflux. Placing the infant in an upright position (Choice A) may increase the risk of regurgitation and aspiration. Burping (Choice B) is important after feeding but may not specifically address the needs of an infant with hydrocephalus. Stimulating the infant by rubbing its feet (Choice D) is unrelated to the specific care needed for an infant with hydrocephalus.
Question 2 of 5
When bathing an infant, what sign does the nurse recognize as a sign of developmental hip dysplasia?
Correct Answer: B
Rationale: The correct answer is B: One leg is shorter than the other. This is a key sign of developmental hip dysplasia in infants. It indicates an imbalance in the hip joint, leading to unequal leg lengths. This can be detected during routine physical examinations by the nurse. Incorrect choices: A: Hypotonicity of the leg muscles - While muscle tone abnormalities can be associated with hip dysplasia, it is not a specific sign that is easily recognizable during bathing. C: Broadening and flattening of the buttocks - This may be a sign of hip dysplasia in older children but is not a typical indicator in infants. D: Two skinfolds on the back of each thigh - Although skinfolds can sometimes be present in infants with hip dysplasia, it is not a reliable or specific sign compared to the leg length discrepancy.
Question 3 of 5
The nurse is advising parents about feeding their infant with phenylketonuria. What formula and/or diet should the nurse suggest?
Correct Answer: D
Rationale: The correct answer is D, substitute Lofenalac for some protein foods. In phenylketonuria (PKU), individuals lack the enzyme to break down phenylalanine found in protein. Lofenalac is a special formula with low phenylalanine content, suitable for PKU patients. Lifelong high-protein diet (A) is incorrect as it would worsen the condition. A formula low in leucine (B) is not specific to PKU. Soy-based formula (C) still contains high levels of phenylalanine.
Question 4 of 5
The nurse is caring for an Rh-negative mother on the postpartum unit. What scenario indicates the need to administer RhoGAM to this patient?
Correct Answer: B
Rationale: Rationale: 1. Rh-negative mother with Rh-positive infant: During delivery, fetal blood can mix with maternal blood leading to sensitization. 2. Sensitization can cause the mother's immune system to produce antibodies against Rh antigen. 3. RhoGAM is administered to prevent antibody formation in Rh-negative mothers carrying Rh-positive infants. Summary: - A: Incorrect. No risk of sensitization as both child and fetus are Rh-negative. - B: Correct. Rh-negative mother with Rh-positive infant at risk for sensitization. - C: Incorrect. Rh factor mismatch between children doesn't require RhoGAM. - D: Incorrect. Being primipara or child's blood type doesn't warrant RhoGAM administration.
Question 5 of 5
Phototherapy is instituted for an infant. What is the most appropriate nursing action for the infant having phototherapy?
Correct Answer: C
Rationale: The correct answer is C: Keep the infant's eyes covered. This is important during phototherapy to protect the infant's eyes from potential damage due to exposure to light. Direct light can harm the infant's developing eyes, so covering them is crucial. Choice A: Cover the infant's head with a hat - This is not necessary for phototherapy as the focus should be on protecting the eyes, not the head. Choice B: Dress the infant lightly in a T-shirt - While dressing the infant lightly is recommended, it is not as critical as protecting the eyes. Choice D: Reposition the infant at least every 4 to 8 hours - Repositioning is important for preventing pressure ulcers but is not directly related to the safety of the eyes during phototherapy.