ATI LPN
ATI Maternal Newborn
1. When checking for the Moro reflex in a newborn, what action should the nurse take?
- A. Hold the newborn vertically under arms and allow one foot to touch the table.
- B. Stimulate the pads of the newborn's hands with stroking or massage.
- C. Stimulate the soles of the newborn's feet on the outer lateral surface of each foot.
- D. Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward.
Correct answer: D
Rationale: The correct action to check for the Moro reflex in a newborn is to hold the newborn in a semi-sitting position and then allow the newborn's head and trunk to fall backward. The Moro reflex is elicited by a sudden loss of support or a loud noise. The normal response involves symmetrical abduction and extension of the arms, followed by their return to the midline in an embracing motion. Choices A, B, and C do not describe the correct method for assessing the Moro reflex and are therefore incorrect.
2. Which type of family-nurse contact will provide you with the best opportunity to observe family dynamics?
- A. Clinic consultation
- B. Group conferences
- C. Home visit
- D. Written communication
Correct answer: C
Rationale: The best opportunity to observe family dynamics is through a home visit. This setting allows the nurse to observe the family in their natural environment, providing valuable insights into their relationships, interactions, and living conditions. By being present in the home, the nurse can better understand the family dynamics, communication patterns, and potential stressors that may not be evident in other forms of contact such as clinic consultations, group conferences, or written communication.
3. A healthcare professional is preparing to administer a cleansing enema to a client. Which of the following actions should the healthcare professional plan to take?
- A. Insert the rectal tube 15.2 cm (6 inches) into the client's rectum
- B. Wear clean gloves before inserting the tubing
- C. Position the client on their left side
- D. Hold the solution bag 91 cm (36 inches) above the client's rectum
Correct answer: C
Rationale: Positioning the client on their left side is crucial when administering an enema as it helps facilitate the flow of the solution into the sigmoid and descending colon. This position allows gravity to assist in the process. Placing the client on the left side is a standard practice to promote optimal outcomes during the procedure. Choices A, B, and D are incorrect. Choice A provides a specific measurement for the insertion depth of the rectal tube, which is not typically necessary to include in the plan of action. Choice B is essential but not specific to enema administration. Choice D mentions holding the solution bag without specifying the correct height, which should typically be around 18-24 inches above the rectum for a cleansing enema.
4. Which type of infectious diseases are required to be reported to the health department?
- A. Staphylococcus aureus infections, including MRSA
- B. Severe cases of flu-like symptoms
- C. Common colds and non-severe respiratory infections
- D. Only contagious diseases like meningitis
Correct answer: A
Rationale: The correct answer is A: Staphylococcus aureus infections, including MRSA. Severe infections like MRSA are required to be reported to the health department as they pose a significant public health risk. Choices B, C, and D are incorrect because severe flu-like symptoms, common colds, and non-severe respiratory infections, and only contagious diseases like meningitis do not fall under the category of infectious diseases that must be reported to the health department.
5. How should a healthcare provider manage care for a patient with a wound infection?
- A. Administer prescribed antibiotics
- B. Clean the wound with saline
- C. Apply a sterile dressing
- D. Monitor for signs of sepsis
Correct answer: A
Rationale: When managing care for a patient with a wound infection, administering prescribed antibiotics is crucial. Antibiotics are necessary to treat the infection and prevent it from worsening. While cleaning the wound with saline and applying a sterile dressing are important components of wound care, the primary treatment for a wound infection is antibiotics. Monitoring for signs of sepsis is also essential, but administering antibiotics promptly is the most critical step in managing a wound infection.
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