ATI RN
Growth and Development Exam
1. This means that Andrew __________.
- A. is in good physical condition
- B. needs assistance in establishing breathing and other vital signs
- C. is in serious danger and should receive emergency medical attention
- D. was in danger at birth, but quickly recovered and is now in good physical condition Answer: B Page Ref: 95 Skill Level: Apply newborn baby’s appearance. Topic: Childbirth Difficulty Level: Difficult
Correct answer: B
Rationale: The statement "Andrew needs assistance in establishing breathing and other vital signs" refers to the initial steps taken to ensure a newborn's well-being after birth. This is a common practice to ensure that the newborn is transitioning smoothly into the outside world and is not indicative of a serious danger that requires emergency medical attention.
2. The HCP orders cultures of the urethral urine, bladder urine, and prostatic fluid. Which instructions would the nurse teach to achieve the first two (2) specimens?
- A. Collect the first 15 mL in one jar and then the next 50 mL in another
- B. Collect three (3) early morning, clean voided urine specimens
- C. Collect the specimens after the HCP massages the prostate
- D. Collect a routine urine specimen for analysis
Correct answer: A
Rationale: To obtain accurate cultures of urethral and bladder urine, the nurse should instruct the patient to collect the first 15 mL of urine in one container and the subsequent 50 mL in another. This method ensures that the specimens are separated appropriately for analysis. Choices B, C, and D are incorrect because collecting three early morning urine specimens, massaging the prostate, or collecting a routine urine specimen would not provide the specific separation of urethral and bladder urine required for this particular test.
3. Which of the following symptoms best describes Murphy’s sign?
- A. Periumbilical ecchymosis exists
- B. On deep palpation and release, pain is elicited
- C. On deep inspiration, pain is elicited and breathing stops
- D. Abdominal muscles are tightened in anticipation of palpation
Correct answer: C
Rationale: Murphy's sign is described as pain elicited on deep inspiration when the examiner's fingers are placed under the right costal margin.
4. A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. What should she do?
- A. Complain to her fellow nurses
- B. Wait until she knows more about the unit
- C. Discuss the problem with her supervisor
- D. Inform the staff that they must volunteer to rotate
Correct answer: C
Rationale: In this scenario, the new head nurse should discuss the problem with her supervisor. This is the most appropriate action as the supervisor is in a position to address staffing concerns effectively and make necessary changes. Complaining to fellow nurses may not lead to a solution, waiting may exacerbate the issue, and demanding staff rotation without proper discussion is not a collaborative approach to resolving the problem.
5. In an immunization clinic, which patient will the nurse identify as not eligible to receive routine immunizations?
- A. An 8-year-old experiencing diarrhea
- B. A 2-year-old with a history of pre-term birth
- C. A 4-year-old with a fever and upper respiratory tract infection
- D. A 6-year-old who has been recently exposed to a classmate with chickenpox
Correct answer: C
Rationale: The nurse should identify the 4-year-old with a fever and upper respiratory tract infection as not eligible to receive routine immunizations. It is contraindicated to administer vaccines in the presence of moderate to severe illness, whether with or without fever, to prevent potential complications or reduced vaccine efficacy.
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