ATI RN
RN Nursing Care of Children Online Practice 2019 A
1. What is the most critical physiologic change required of newborns at birth?
- A. Transition from fetal to neonatal breathing
- B. Body temperature maintenance
- C. Stabilization of fluid and electrolytes
- D. Closure of fetal shunts in the heart
Correct answer: A
Rationale: The correct answer is A: Transition from fetal to neonatal breathing. The onset of breathing is the most immediate and critical physiologic change required for the transition to extrauterine life. Factors that interfere with this normal transition increase fetal asphyxia, which is a condition of hypoxemia, hypercapnia, and acidosis. While body temperature maintenance, stabilization of fluid and electrolytes, and closure of fetal shunts in the heart are crucial changes in the transition to extrauterine life, breathing and the exchange of oxygen for carbon dioxide must take precedence as they are essential for newborn survival.
2. A nurse is performing an assessment on a client with a suspected diagnosis of acute pancreatitis. The nurse assesses the client, knowing that which of the following is a hallmark sign of this disorder?
- A. Severe abdominal pain relieved by vomiting
- B. Severe abdominal pain that is unrelieved by vomiting
- C. Hypothermia
- D. Epigastric pain radiating to the neck area
Correct answer: B
Rationale: A hallmark sign of acute pancreatitis is severe abdominal pain that is not relieved by vomiting. Nausea and vomiting are common presenting symptoms, with vomitus typically consisting of gastric and duodenal contents. Hypothermia is not a hallmark sign of acute pancreatitis. Fever, typically less than 38 degrees centigrade, is more common. Epigastric pain radiating to the neck area is not a characteristic sign of acute pancreatitis. Therefore, choice B is the correct answer.
3. A nurse is preparing to administer an enema to a client. Which of the following actions should the nurse take?
- A. Place the client in a high-Fowler's position
- B. Assist the client to the left Sims' position
- C. Insert the enema tubing 2.5 cm (1 in) into the rectum
- D. Lubricate the tip of the enema tubing with petroleum jelly
Correct answer: B
Rationale: The correct answer is to assist the client to the left Sims' position when administering an enema. This position helps facilitate the flow of the enema solution into the rectum. Placing the client in a high-Fowler's position (Choice A) is not ideal for administering an enema. Inserting the enema tubing 2.5 cm (1 in) into the rectum (Choice C) is incorrect as it should be inserted 7.5-10 cm (3-4 in) for an adult. Lubricating the tip of the enema tubing with petroleum jelly (Choice D) is a correct step to ease insertion but is not the most critical action among the choices provided.
4. What aspect of this woman's current health status would contraindicate the use of oral contraceptives?
- A. The woman has a diagnosis of type 2 diabetes.
- B. The woman has asthma and uses inhaled corticosteroids and bronchodilators.
- C. The woman has a family history of breast cancer.
- D. The woman takes an antiplatelet medication for coronary artery disease.
Correct answer: A
Rationale: The correct answer is A. Women with type 2 diabetes are at higher risk of developing cardiovascular complications. Oral contraceptives further increase this risk due to their potential effects on blood pressure, lipid metabolism, and clotting factors. Choice B is incorrect as inhaled corticosteroids and bronchodilators do not contraindicate the use of oral contraceptives. Choice C is incorrect as a family history of breast cancer does not directly contraindicate the use of oral contraceptives. Choice D is also incorrect as taking an antiplatelet medication for coronary artery disease does not necessarily contraindicate the use of oral contraceptives.
5. What is the appropriate action for a patient experiencing a severe allergic reaction?
- A. Administer epinephrine
- B. Administer antihistamines
- C. Administer corticosteroids
- D. Administer oxygen
Correct answer: A
Rationale: The correct answer is to administer epinephrine. Epinephrine is the first-line treatment for severe allergic reactions as it helps reverse the symptoms rapidly by constricting blood vessels, increasing heart rate, and opening airways. Antihistamines (Choice B) may help with mild allergic reactions but are not effective for severe cases. Corticosteroids (Choice C) are used to reduce inflammation and are typically not the first-line treatment for acute severe allergic reactions. Administering oxygen (Choice D) may be necessary to support breathing in severe cases, but epinephrine is the primary treatment to reverse the allergic reaction symptoms.