when assessing a 30 year old female who was sexually assaulted it is most important for you to
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Nursing Elites

ATI LPN

ATI Pediatrics Proctored Test

1. When assessing a 30-year-old female who was sexually assaulted, what is the MOST important action for you to take?

Correct answer: D

Rationale: In cases of sexual assault, the priority is to address any life-threatening injuries first before proceeding with other aspects of care. Although preserving evidence and approaching the situation with sensitivity are crucial, immediate treatment of life-threatening conditions takes precedence to ensure the patient's well-being and safety. Having a female healthcare provider, advising against showering or changing clothes, and acknowledging the patient as a potential crime scene are important but secondary considerations compared to addressing any life-threatening injuries promptly.

2. Why is a prolapsed umbilical cord dangerous?

Correct answer: C

Rationale: A prolapsed umbilical cord is dangerous because the baby's head may compress the cord, cutting off its supply of oxygen. This compression can lead to oxygen deprivation, potentially causing significant harm to the baby. Immediate medical intervention is crucial in such cases to prevent adverse outcomes.

3. What characteristic indicates that a mass on a newborn's head is a cephalohematoma?

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.

4. The nurse is assessing a postpartum client's fundus. Where should the nurse expect to find the fundus 24 hours after delivery?

Correct answer: A

Rationale: After delivery, the fundus is expected to be at the level of the umbilicus 24 hours postpartum. This position indicates that the uterus is involuting properly. Assessing the fundal height helps monitor the progress of uterine involution and can identify any potential complications like postpartum hemorrhage.

5. A 30-year-old woman has severe lower abdominal pain and light vaginal bleeding. She tells you that her last menstrual period was 2 months ago. On the basis of these findings, you should suspect:

Correct answer: C

Rationale: Severe lower abdominal pain, light vaginal bleeding, and a history of missed periods are concerning for an ectopic pregnancy. The absence of a normal menstrual period along with these symptoms raises suspicion for an ectopic pregnancy, which requires immediate medical attention due to the risk of rupture and life-threatening complications. A normal pregnancy would typically present with different symptoms such as a positive pregnancy test and typical signs of early pregnancy. A ruptured ovarian cyst may present with similar symptoms but typically lacks the history of missed periods. A spontaneous abortion usually involves heavier bleeding and tissue passage, which is not described in this scenario.

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