ATI Custom NUR209 Final Assessment Summer 1
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Free ATI Custom NUR209 Final Assessment Summer 1 Questions
1. An infant has just undergone surgical repair of a myelomeningocele. What is the priority nursing intervention to perform immediately following the procedure?
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Limit caregiver visitation
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Monitor head circumference
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Measure abdominal circumference
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Position the infant supine
Explanation
Explanation
Correct Answer: (B) Monitor head circumference
Following surgical repair of a myelomeningocele, the priority nursing intervention is to monitor head circumference. The closure of the defect alters cerebrospinal fluid dynamics and significantly increases the risk of developing hydrocephalus, which is the most common complication following myelomeningocele repair. Measuring and monitoring head circumference detects early signs of increased intracranial pressure and hydrocephalus requiring prompt intervention.
Why Other Options are Incorrect:
A. Limit caregiver visitation Limiting visitation is not a priority postoperative intervention for myelomeningocele repair. Family-centered care promotes caregiver presence and involvement in the infant's recovery, and restricting visitation is not an evidence-based intervention for this condition.
C. Measure abdominal circumference Abdominal circumference measurement is used to monitor for abdominal distension in conditions such as necrotizing enterocolitis or intestinal obstruction. It is not a priority assessment specific to myelomeningocele repair.
D. Position the infant supine Positioning the infant supine is actually contraindicated immediately after myelomeningocele repair as it places pressure directly on the surgical repair site. The infant should be positioned prone or on the side to protect the surgical closure and prevent wound dehiscence or infection.
Correct Answer: (B) Monitor head circumference
Following surgical repair of a myelomeningocele, the priority nursing intervention is to monitor head circumference. The closure of the defect alters cerebrospinal fluid dynamics and significantly increases the risk of developing hydrocephalus, which is the most common complication following myelomeningocele repair. Measuring and monitoring head circumference detects early signs of increased intracranial pressure and hydrocephalus requiring prompt intervention.
Why Other Options are Incorrect:
A. Limit caregiver visitation Limiting visitation is not a priority postoperative intervention for myelomeningocele repair. Family-centered care promotes caregiver presence and involvement in the infant's recovery, and restricting visitation is not an evidence-based intervention for this condition.
C. Measure abdominal circumference Abdominal circumference measurement is used to monitor for abdominal distension in conditions such as necrotizing enterocolitis or intestinal obstruction. It is not a priority assessment specific to myelomeningocele repair.
D. Position the infant supine Positioning the infant supine is actually contraindicated immediately after myelomeningocele repair as it places pressure directly on the surgical repair site. The infant should be positioned prone or on the side to protect the surgical closure and prevent wound dehiscence or infection.
2. A nurse in a provider's office is planning care for a client who has a new diagnosis of polycystic ovarian syndrome. The nurse should plan to monitor which of the following laboratory values?
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Liver function
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Thyroid-stimulating hormone
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Glucose
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BUN
Explanation
Explanation
Polycystic ovarian syndrome (PCOS) is strongly associated with insulin resistance and an increased risk of developing type 2 diabetes mellitus. Monitoring glucose levels, including fasting glucose and hemoglobin A1c, is essential in the management of PCOS to identify metabolic complications early and guide interventions to prevent progression to diabetes.
Why the other options are incorrect:
A. Liver function Liver function tests are not a standard monitoring priority in the routine management of PCOS. They may be relevant if the client develops non-alcoholic fatty liver disease, which can be associated with metabolic syndrome, but it is not the primary laboratory value to monitor in a new PCOS diagnosis.
B. Thyroid-stimulating hormone While thyroid disorders can present with symptoms similar to PCOS and should be ruled out during the diagnostic process, TSH is not the ongoing laboratory priority for monitoring a client already diagnosed with PCOS. Glucose monitoring takes precedence due to the strong insulin resistance component of the condition.
D. BUN BUN is a measure of kidney function and is not directly related to the pathophysiology or management of PCOS. It is not a standard monitoring laboratory value for this condition.
Polycystic ovarian syndrome (PCOS) is strongly associated with insulin resistance and an increased risk of developing type 2 diabetes mellitus. Monitoring glucose levels, including fasting glucose and hemoglobin A1c, is essential in the management of PCOS to identify metabolic complications early and guide interventions to prevent progression to diabetes.
Why the other options are incorrect:
A. Liver function Liver function tests are not a standard monitoring priority in the routine management of PCOS. They may be relevant if the client develops non-alcoholic fatty liver disease, which can be associated with metabolic syndrome, but it is not the primary laboratory value to monitor in a new PCOS diagnosis.
B. Thyroid-stimulating hormone While thyroid disorders can present with symptoms similar to PCOS and should be ruled out during the diagnostic process, TSH is not the ongoing laboratory priority for monitoring a client already diagnosed with PCOS. Glucose monitoring takes precedence due to the strong insulin resistance component of the condition.
D. BUN BUN is a measure of kidney function and is not directly related to the pathophysiology or management of PCOS. It is not a standard monitoring laboratory value for this condition.
3. A nurse is caring for an infant diagnosed with a cleft palate. Which complication should the nurse recognize as most common in this condition?
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Pyloric Stenosis
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Otitis media
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Congenital heart defect
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Intussusception
Explanation
Explanation
Correct Answer: (B) Otitis media
Otitis media is the most common complication associated with cleft palate. The abnormal palate structure impairs the normal function of the Eustachian tubes, preventing proper drainage of the middle ear. This leads to fluid accumulation, recurrent ear infections, and potential hearing loss. Children with cleft palate frequently require tympanostomy tubes to manage chronic otitis media.
Why the other options are incorrect:
A. Pyloric Stenosis Pyloric stenosis is a condition involving obstruction of the gastric outlet and has no direct anatomical or physiological link to cleft palate.
C. Congenital heart defect While cleft palate can be associated with certain genetic syndromes that include cardiac defects, it is not the most common complication directly caused by cleft palate itself.
D. Intussusception Intussusception is a bowel obstruction in which one segment of the intestine telescopes into another and has no association with cleft palate.
Correct Answer: (B) Otitis media
Otitis media is the most common complication associated with cleft palate. The abnormal palate structure impairs the normal function of the Eustachian tubes, preventing proper drainage of the middle ear. This leads to fluid accumulation, recurrent ear infections, and potential hearing loss. Children with cleft palate frequently require tympanostomy tubes to manage chronic otitis media.
Why the other options are incorrect:
A. Pyloric Stenosis Pyloric stenosis is a condition involving obstruction of the gastric outlet and has no direct anatomical or physiological link to cleft palate.
C. Congenital heart defect While cleft palate can be associated with certain genetic syndromes that include cardiac defects, it is not the most common complication directly caused by cleft palate itself.
D. Intussusception Intussusception is a bowel obstruction in which one segment of the intestine telescopes into another and has no association with cleft palate.
4. A nurse is caring for a 5-year-old child who is postoperative following a tonsillectomy. Which of the following pain scales should the nurse use to determine the child's pain level?
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NIPS (Neonatal Infant Pain Scale)
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FACES
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Numeric Rating Scale (NRS)
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FLACC
Explanation
Explanation
Correct Answer: (B) FACES
The FACES pain scale is the appropriate tool for a 5-year-old child. It uses a series of illustrated facial expressions ranging from a happy face representing no pain to a crying face representing the worst pain, allowing young children who may not yet have the cognitive or verbal ability to use numeric scales to communicate their pain level by pointing to the face that best represents how they feel.
Why Other Options are Incorrect:
A. NIPS (Neonatal Infant Pain Scale) The NIPS is designed for neonates and premature infants and assesses pain through behavioral indicators such as facial expression, crying, and limb movement. It is not appropriate for a 5-year-old child who is able to participate in self-reporting.
C. Numeric Rating Scale (NRS) The NRS requires the client to assign a number from 0 to 10 to describe their pain intensity. This scale is most appropriate for older children aged 9 and above and adults who have the cognitive ability to understand abstract numeric representation of pain intensity.
D. FLACC The FLACC scale assesses Face, Legs, Activity, Cry, and Consolability and is used for infants and children between 2 months and 7 years who are unable to self-report pain, such as those who are sedated, cognitively impaired, or nonverbal. A 5-year-old who is alert and cooperative postoperatively can self-report using the FACES scale, making FACES the more appropriate choice.
Correct Answer: (B) FACES
The FACES pain scale is the appropriate tool for a 5-year-old child. It uses a series of illustrated facial expressions ranging from a happy face representing no pain to a crying face representing the worst pain, allowing young children who may not yet have the cognitive or verbal ability to use numeric scales to communicate their pain level by pointing to the face that best represents how they feel.
Why Other Options are Incorrect:
A. NIPS (Neonatal Infant Pain Scale) The NIPS is designed for neonates and premature infants and assesses pain through behavioral indicators such as facial expression, crying, and limb movement. It is not appropriate for a 5-year-old child who is able to participate in self-reporting.
C. Numeric Rating Scale (NRS) The NRS requires the client to assign a number from 0 to 10 to describe their pain intensity. This scale is most appropriate for older children aged 9 and above and adults who have the cognitive ability to understand abstract numeric representation of pain intensity.
D. FLACC The FLACC scale assesses Face, Legs, Activity, Cry, and Consolability and is used for infants and children between 2 months and 7 years who are unable to self-report pain, such as those who are sedated, cognitively impaired, or nonverbal. A 5-year-old who is alert and cooperative postoperatively can self-report using the FACES scale, making FACES the more appropriate choice.
5. An 18-hour-old infant with hyperbilirubinemia is placed under phototherapy bank lights. Which of the following is an appropriate intervention for this infant?
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Keep eye shields on at all times, including when breastfeeding
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Tightly swaddle the infant in blanket
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Expose as much of the infant's skin to the lights as possible
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Keep skin moisturized with lotion
Explanation
Explanation
Correct Answer: (C) Expose as much of the infant's skin to the lights as possible
Phototherapy works by converting bilirubin in the skin into a water-soluble form that can be excreted in urine and stool. Maximizing skin surface area exposure to the phototherapy lights increases the effectiveness of treatment by allowing more bilirubin to be broken down. The infant should be placed with minimal clothing, typically only a diaper, to maximize light exposure.
Why Other Options are Incorrect:
A. Keep eye shields on at all times, including when breastfeeding Eye shields are essential during phototherapy to protect the infant's eyes from the intense light, which can cause retinal damage. However, the shields should be removed during breastfeeding and direct interaction with caregivers to allow for eye contact, bonding, and assessment of the eyes for irritation or infection.
B. Tightly swaddle the infant in blanket Swaddling during phototherapy covers the skin and significantly reduces the surface area exposed to the therapeutic lights, making treatment far less effective. The infant should be unswaddled and dressed minimally to maximize skin exposure.
D. Keep skin moisturized with lotion Applying lotion to the skin during phototherapy is contraindicated as it can absorb the light and potentially cause skin burns. The skin should be kept clean and dry during phototherapy treatment.
Correct Answer: (C) Expose as much of the infant's skin to the lights as possible
Phototherapy works by converting bilirubin in the skin into a water-soluble form that can be excreted in urine and stool. Maximizing skin surface area exposure to the phototherapy lights increases the effectiveness of treatment by allowing more bilirubin to be broken down. The infant should be placed with minimal clothing, typically only a diaper, to maximize light exposure.
Why Other Options are Incorrect:
A. Keep eye shields on at all times, including when breastfeeding Eye shields are essential during phototherapy to protect the infant's eyes from the intense light, which can cause retinal damage. However, the shields should be removed during breastfeeding and direct interaction with caregivers to allow for eye contact, bonding, and assessment of the eyes for irritation or infection.
B. Tightly swaddle the infant in blanket Swaddling during phototherapy covers the skin and significantly reduces the surface area exposed to the therapeutic lights, making treatment far less effective. The infant should be unswaddled and dressed minimally to maximize skin exposure.
D. Keep skin moisturized with lotion Applying lotion to the skin during phototherapy is contraindicated as it can absorb the light and potentially cause skin burns. The skin should be kept clean and dry during phototherapy treatment.
6. The nurse educates the parents on actions to prevent sudden infant death syndrome. Which observation indicates the teaching has been effective?
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The newborn is co-sleeping in the caregiver's bed
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Newborn is placed in bassinet on the back
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Mother removes pacifier from the newborn's mouth
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Newborn is placed in bassinet with blanket draped over them
Explanation
Explanation
Correct Answer: (B) Newborn is placed in bassinet on the back
Placing a newborn on their back to sleep is the single most important recommendation from the American Academy of Pediatrics for reducing the risk of SIDS. The back-sleeping position keeps the airway open and reduces the risk of rebreathing carbon dioxide. Using a separate, firm sleep surface such as a bassinet further reduces risk by eliminating soft bedding and co-sleeping hazards.
Why Other Options are Incorrect:
A. The newborn is co-sleeping in the caregiver's bed Co-sleeping significantly increases the risk of SIDS and accidental suffocation. Infants should always sleep on a separate, firm surface.
C. Mother removes pacifier from the newborn's mouth Pacifier use during sleep is actually recommended as a protective measure against SIDS. The mother should not remove it; the infant may naturally release it during sleep.
D. Newborn is placed in bassinet with blanket draped over them Loose bedding such as blankets, pillows, and bumper pads in the sleep environment are major SIDS risk factors. The sleep surface should remain bare and firm.
Correct Answer: (B) Newborn is placed in bassinet on the back
Placing a newborn on their back to sleep is the single most important recommendation from the American Academy of Pediatrics for reducing the risk of SIDS. The back-sleeping position keeps the airway open and reduces the risk of rebreathing carbon dioxide. Using a separate, firm sleep surface such as a bassinet further reduces risk by eliminating soft bedding and co-sleeping hazards.
Why Other Options are Incorrect:
A. The newborn is co-sleeping in the caregiver's bed Co-sleeping significantly increases the risk of SIDS and accidental suffocation. Infants should always sleep on a separate, firm surface.
C. Mother removes pacifier from the newborn's mouth Pacifier use during sleep is actually recommended as a protective measure against SIDS. The mother should not remove it; the infant may naturally release it during sleep.
D. Newborn is placed in bassinet with blanket draped over them Loose bedding such as blankets, pillows, and bumper pads in the sleep environment are major SIDS risk factors. The sleep surface should remain bare and firm.
7. A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse expect?
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Constipation
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Pain
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Bradycardia
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High fever
Explanation
Explanation
Correct Answer: (B) Pain
Severe pain is the hallmark manifestation of a sickle cell crisis, also known as a vaso-occlusive crisis. Sickled red blood cells obstruct blood flow in small vessels, causing ischemia and infarction of surrounding tissues. This leads to intense, acute pain that can affect any part of the body including the bones, chest, abdomen, and joints, and is the primary reason children with sickle cell disease seek emergency care.
Why Other Options are Incorrect:
A. Constipation Constipation is not a characteristic finding of sickle cell crisis. While opioid analgesics used to treat sickle cell pain can cause constipation as a side effect, it is not a manifestation of the crisis itself.
C. Bradycardia Sickle cell crisis is associated with tachycardia rather than bradycardia, as the body compensates for anemia and tissue hypoxia by increasing the heart rate to maintain adequate oxygen delivery.
D. High fever While fever can sometimes accompany sickle cell crisis, particularly if infection is the precipitating cause, high fever is not the defining or expected hallmark finding of a vaso-occlusive crisis. Severe pain is the primary expected manifestation.
Correct Answer: (B) Pain
Severe pain is the hallmark manifestation of a sickle cell crisis, also known as a vaso-occlusive crisis. Sickled red blood cells obstruct blood flow in small vessels, causing ischemia and infarction of surrounding tissues. This leads to intense, acute pain that can affect any part of the body including the bones, chest, abdomen, and joints, and is the primary reason children with sickle cell disease seek emergency care.
Why Other Options are Incorrect:
A. Constipation Constipation is not a characteristic finding of sickle cell crisis. While opioid analgesics used to treat sickle cell pain can cause constipation as a side effect, it is not a manifestation of the crisis itself.
C. Bradycardia Sickle cell crisis is associated with tachycardia rather than bradycardia, as the body compensates for anemia and tissue hypoxia by increasing the heart rate to maintain adequate oxygen delivery.
D. High fever While fever can sometimes accompany sickle cell crisis, particularly if infection is the precipitating cause, high fever is not the defining or expected hallmark finding of a vaso-occlusive crisis. Severe pain is the primary expected manifestation.
8. A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take?
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Ask another nurse to verify the heart rate.
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Call the provider to further assess the newborn.
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Prepare the newborn for transport to the NICU.
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Document this as an expected finding.
Explanation
Explanation
Correct Answer: (D) Document this as an expected finding
The normal heart rate for a newborn ranges from 110 to 160 beats per minute. An apical heart rate of 130 beats per minute falls well within this expected range and requires no further intervention. The nurse should document this finding as a normal assessment. No escalation, verification, or transfer is warranted for a heart rate that is within normal limits.
Why the other options are incorrect:
A. Ask another nurse to verify the heart rate Verification by another nurse is appropriate when an abnormal or unexpected finding is obtained. A rate of 130 beats per minute is normal and does not require confirmation.
B. Call the provider to further assess the newborn Contacting the provider is unnecessary for a finding that is within the expected normal range for a newborn. This would constitute inappropriate escalation.
C. Prepare the newborn for transport to the NICU NICU transfer is reserved for newborns with serious clinical concerns. A heart rate of 130 beats per minute is a normal finding and does not indicate any need for intensive care.
Correct Answer: (D) Document this as an expected finding
The normal heart rate for a newborn ranges from 110 to 160 beats per minute. An apical heart rate of 130 beats per minute falls well within this expected range and requires no further intervention. The nurse should document this finding as a normal assessment. No escalation, verification, or transfer is warranted for a heart rate that is within normal limits.
Why the other options are incorrect:
A. Ask another nurse to verify the heart rate Verification by another nurse is appropriate when an abnormal or unexpected finding is obtained. A rate of 130 beats per minute is normal and does not require confirmation.
B. Call the provider to further assess the newborn Contacting the provider is unnecessary for a finding that is within the expected normal range for a newborn. This would constitute inappropriate escalation.
C. Prepare the newborn for transport to the NICU NICU transfer is reserved for newborns with serious clinical concerns. A heart rate of 130 beats per minute is a normal finding and does not indicate any need for intensive care.
9. Which of the following factors would the nurse identify as risk factors for abuse in children? (Select All that Apply.)
- The parents have a strong support system
- Child with developmental disabilities
- A parent with a history of experiencing abuse during their own childhood
- Poverty/Financial strain
- Premature birth
Explanation
Explanation
Children with developmental disabilities require more complex care, which can increase caregiver stress and the risk of abuse. Parents who were abused themselves are at a higher risk of repeating the cycle of abuse. Poverty and financial strain create chronic stress that can contribute to abusive behaviors. Premature birth is a risk factor because it can disrupt early bonding and increase caregiving demands, both of which elevate abuse risk.
Why the other options are incorrect:
A. The parents have a strong support system A strong support system is actually a protective factor against child abuse, not a risk factor. Social support helps reduce caregiver stress and provides resources that lower the likelihood of abusive behavior.
Children with developmental disabilities require more complex care, which can increase caregiver stress and the risk of abuse. Parents who were abused themselves are at a higher risk of repeating the cycle of abuse. Poverty and financial strain create chronic stress that can contribute to abusive behaviors. Premature birth is a risk factor because it can disrupt early bonding and increase caregiving demands, both of which elevate abuse risk.
Why the other options are incorrect:
A. The parents have a strong support system A strong support system is actually a protective factor against child abuse, not a risk factor. Social support helps reduce caregiver stress and provides resources that lower the likelihood of abusive behavior.
10. A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions?
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Turn the newborn's head quickly to one side.
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Hold the newborn vertically allowing one foot to touch the table surface.
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Place a finger at the base of the newborn's toes.
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Perform a sharp hand clap near the infant.
Explanation
Explanation
Correct Answer: (D) Perform a sharp hand clap near the infant.
The Moro reflex, also known as the startle reflex, is elicited by a sudden loud noise or by simulating a sensation of falling. Performing a sharp hand clap near the infant produces a sudden auditory stimulus that triggers the reflex response, in which the newborn symmetrically abducts and extends the arms, then brings them back toward the midline in an embracing motion, often accompanied by crying.
Why Other Options are Incorrect:
A. Turn the newborn's head quickly to one side. Turning the newborn's head quickly to one side elicits the tonic neck reflex, also known as the fencing reflex, where the arm and leg on the side the head is turned toward extend while the opposite limbs flex.
B. Hold the newborn vertically allowing one foot to touch the table surface. Holding the newborn vertically and allowing a foot to touch a flat surface elicits the stepping reflex, also called the walking or dance reflex, where the newborn makes stepping movements as if walking.
C. Place a finger at the base of the newborn's toes. Placing a finger at the base of the toes elicits the plantar grasp reflex, where the toes curl downward in a grasping motion. This is distinct from the Moro reflex.
Correct Answer: (D) Perform a sharp hand clap near the infant.
The Moro reflex, also known as the startle reflex, is elicited by a sudden loud noise or by simulating a sensation of falling. Performing a sharp hand clap near the infant produces a sudden auditory stimulus that triggers the reflex response, in which the newborn symmetrically abducts and extends the arms, then brings them back toward the midline in an embracing motion, often accompanied by crying.
Why Other Options are Incorrect:
A. Turn the newborn's head quickly to one side. Turning the newborn's head quickly to one side elicits the tonic neck reflex, also known as the fencing reflex, where the arm and leg on the side the head is turned toward extend while the opposite limbs flex.
B. Hold the newborn vertically allowing one foot to touch the table surface. Holding the newborn vertically and allowing a foot to touch a flat surface elicits the stepping reflex, also called the walking or dance reflex, where the newborn makes stepping movements as if walking.
C. Place a finger at the base of the newborn's toes. Placing a finger at the base of the toes elicits the plantar grasp reflex, where the toes curl downward in a grasping motion. This is distinct from the Moro reflex.
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