ATI RN
Maternity and Pediatric Nursing 4th Edition Test Bank Questions
Question 1 of 5
which of the following must be present in order for an infant with complete transposition of the great vessels to survive at birth?
Correct Answer: C
Rationale: In an infant with complete transposition of the great vessels, the survival at birth depends on the presence of a patent ductus arteriosus (PDA) to allow mixing of oxygenated and deoxygenated blood. In this condition, the aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle, leading to separate circulatory pathways for oxygenated and deoxygenated blood. The survival of the infant is dependent on the remaining fetal shunts, such as a PDA, to maintain an adequate mixing of blood until corrective surgery can be performed. Therefore, the presence of a PDA is essential for the survival of an infant with complete transposition of the great vessels at birth.
Question 2 of 5
The nurse is examining 12-month-old Amy, who was brought to the clinic for persistent diaper rash. The nurse finds perianal inflammation with satellite lesions that cross the inguinal folds. What is most likely the cause of the diaper rash?
Correct Answer: B
Rationale: The presentation of perianal inflammation with satellite lesions that cross the inguinal folds is highly suggestive of a Candida albicans (yeast) diaper rash. Yeast diaper rash is characterized by redness, swollenness, and usually involves the skin folds. The warm, moist environment created by a diaper provides an ideal setting for Candida albicans to grow and cause a rash. The presence of satellite lesions that cross the inguinal folds further supports the diagnosis of a yeast infection rather than other causes like impetigo, irritation from urine and feces, or infrequent diapering. Treatment for yeast diaper rash typically involves antifungal creams or ointments.
Question 3 of 5
A client tells the nurse that she has been working hard for the last 3 months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the client's efforts, the nurse should check:
Correct Answer: D
Rationale: Checking the glycosylated hemoglobin (HbA1c) level is the most appropriate way to determine the effectiveness of the client's efforts to control type 2 diabetes mellitus over the past few months. HbA1c provides an average of the blood glucose levels over the past 2-3 months, reflecting how well the client has been managing their diabetes. This test is not affected by recent food intake or physical activity, making it a reliable indicator of long-term glucose control. Unlike fasting blood glucose levels or urine glucose levels, which can fluctuate throughout the day, HbA1c gives a more comprehensive view of glucose control and helps guide treatment decisions.
Question 4 of 5
The pediatric nurse advises a parent how to best convey the circumstances surrounding the sudden death of an 18-month-old patient to a four-year-old sibling. The nurse anticipates that the sibling:
Correct Answer: A
Rationale: Young children often struggle with understanding death and may internalize feelings of guilt, believing they had a role in the event.
Question 5 of 5
If a client with increased pressure (ICP) demonstrates decorticate posturing, the nurse will observe:
Correct Answer: B
Rationale: Decorticate posturing is characterized by flexion of elbows, wrists, and fingers; extension of elbows and knees; plantar flexion of the feet. This type of posturing typically indicates severe damage to the cerebral hemispheres or impairment of the corticospinal tract. When a client with increased intracranial pressure (ICP) displays decorticate posturing, it suggests significant brain injury and dysfunction. This abnormal posturing is a classic sign that requires immediate medical attention and intervention.