ATI LPN
ATI Pediatrics Proctored Exam 2023 with NGN
1. What characteristic indicates that a mass on a newborn's head is a cephalohematoma?
- A. The mass appears on the second day after birth.
- B. The mass grows larger when the newborn cries.
- C. The head appears asymmetrical.
- D. The mass is located on only one side of the head.
Correct answer: A
Rationale: A cephalohematoma typically appears between the first and second days after birth, making choice A the correct answer. It results from blood vessel rupture between a cranial bone and the periosteal membrane. Choices B, C, and D are incorrect because the growth of the mass when the newborn cries, asymmetrical head appearance, or the mass being located on only one side of the head are not specific indicators of a cephalohematoma.
2. The healthcare professional is assessing a client who presents with jaundice. Which assessment finding is most important for the healthcare professional to follow up on?
- A. Urine specific gravity of 1.03
- B. Frothy, tea-colored urine
- C. Clay-colored stools
- D. Elevated serum amylase and lipase levels
Correct answer: D
Rationale: Elevated serum amylase and lipase levels are indicative of pancreatitis, a serious condition that can manifest with jaundice. Timely follow-up is crucial to manage pancreatitis and its complications effectively in a jaundiced client. Choices A, B, and C are less critical in this scenario. Urine specific gravity within normal range, frothy tea-colored urine, and clay-colored stools can be associated with various conditions but are not directly indicative of pancreatitis, which is the most concerning condition associated with jaundice.
3. A client with dysphagia and at risk for aspiration needs care planning. Which intervention should the nurse include in the plan?
- A. Encourage the client to drink thickened liquids.
- B. Instruct the client to swallow with chin tucked.
- C. Provide the client with a cup with a lid.
- D. Place the client in Fowler's position for meals.
Correct answer: D
Rationale: Placing the client in Fowler's position is crucial in preventing aspiration as it helps maintain an open airway and reduces the risk of food or liquid entering the lungs during swallowing. This position promotes safer swallowing and minimizes the chances of aspiration pneumonia. Choices A, B, and C are less effective interventions for preventing aspiration. Encouraging the client to drink thickened liquids may help, but the position is more critical. Instructing the client to swallow with chin tucked is beneficial for some individuals but not as effective as positioning. Providing a cup with a lid does not directly address the risk of aspiration associated with dysphagia.
4. A patient with deep vein thrombosis (DVT) is prescribed warfarin. Which dietary instruction should the nurse provide?
- A. Avoid foods high in vitamin K.
- B. Increase intake of dairy products.
- C. Limit intake of citrus fruits.
- D. Avoid high-sodium foods.
Correct answer: A
Rationale: Patients on warfarin should avoid foods high in vitamin K because vitamin K can interfere with the anticoagulant effect of the medication. Warfarin works by inhibiting vitamin K-dependent clotting factors, so consuming large amounts of vitamin K-rich foods may decrease the effectiveness of the medication. Choices B, C, and D are incorrect. Increasing intake of dairy products, limiting citrus fruits, or avoiding high-sodium foods are not directly related to the mechanism of action of warfarin or its dietary considerations.
5. A client who is postpartum has a slightly boggy and displaced fundus to the right. Which of the following actions should the nurse take based on these findings?
- A. Encourage the client to perform Kegel exercises.
- B. Encourage the client to move to the left lateral position.
- C. Ask the client to rate her pain.
- D. Assist the client to the bathroom to void.
Correct answer: D
Rationale: A displaced and boggy fundus in a postpartum client typically indicates a full bladder, which can impede uterine contractions and increase the risk of postpartum hemorrhage. Assisting the client to the bathroom to void helps ensure the bladder is empty, aiding the fundus to contract and reducing the risk of complications. Encouraging Kegel exercises, changing positions, or assessing pain would not directly address the issue of the boggy fundus caused by a full bladder.
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