ATI NUR 209 Final Assessment

Correct Answer: Administer parental antibiotics

Explanation

The priority intervention for an antenatal client at 32 weeks' gestation with premature rupture of membranes (PROM) is to administer parental antibiotics. Premature rupture of membranes increases the risk of infection, particularly chorioamnionitis, which can lead to serious complications for both the mother and the baby, including infection and preterm labor. Antibiotics are typically administered to reduce this risk and prevent infection. In preterm pregnancies, preventing infection is crucial because it can accelerate labor or harm the baby.

Why other options are wrong

Provide emotional support: While providing emotional support is important for any patient, it is not the priority in this situation. The immediate concern with PROM is preventing infection and managing risks related to the premature rupture. Emotional support should follow after addressing the more critical clinical needs.

Assess cervical dilation every 2 hours: While monitoring cervical dilation can be important if labor is suspected, the client is not exhibiting signs of labor at the moment. The priority is preventing infection, which is a higher risk at this point than checking for labor progression.

Prepare for delivery: Although preterm delivery may be necessary if complications arise, the priority is to prevent infection and manage the preterm birth risks through antibiotics and observation. Immediate preparation for delivery would not be warranted unless there are signs of labor or other complications.

Summary

For a client with premature rupture of membranes (PROM) at 32 weeks, the priority intervention is administering antibiotics to reduce the risk of infection. This is crucial because infection can lead to further complications such as chorioamnionitis, premature labor, or harm to the baby. Other interventions, such as emotional support or monitoring cervical dilation, are important but should come after addressing the risk of infection.

Correct Answers: Wide pulse pressure, C. Bounding peripheral pulses, F. A continuous "machinery-like" heart murmur

Why These Answers Are Correct:

Patent ductus arteriosus (PDA) is a condition in which the ductus arteriosus—a fetal blood vessel that connects the pulmonary artery to the descending aorta—fails to close after birth, allowing oxygenated blood to flow from the aorta back into the pulmonary artery. This left-to-right shunting of blood leads to increased pulmonary circulation and decreased systemic perfusion.

Wide pulse pressure is a classic sign of PDA. The diastolic pressure is decreased due to runoff of blood into the pulmonary circulation, while systolic pressure remains elevated, resulting in a widened pulse pressure.

Bounding peripheral pulses occur due to increased stroke volume and the rapid runoff of blood through the PDA during diastole, contributing to a strong, bounding pulse.

 A continuous "machinery-like" heart murmur is the hallmark auscultatory finding of PDA. It is best heard at the left upper sternal border, and results from continuous turbulent blood flow between the aorta and pulmonary artery throughout systole and diastole.

Why Other Options Are Wrong:

Cyanosis of the extremities is not typical in isolated PDA unless it is part of a more complex congenital heart defect or there is reversal of shunt direction (which would only occur in advanced, untreated cases with pulmonary hypertension). In a typical left-to-right PDA, pulmonary overcirculation occurs without systemic cyanosis.

 Decreased urine output is not a common early sign of PDA. While severe PDA can lead to heart failure and hypotension, which could affect renal perfusion, this is not an early or consistent finding in isolated PDA.

Bradycardia is not associated with PDA. On the contrary, if any heart rate change occurs in PDA with complications like heart failure or respiratory distress, tachycardia is more common, not bradycardia.

Summary:

The correct answers are A. Wide pulse pressure, C. Bounding peripheral pulses, and F. A continuous "machinery-like" heart murmur, as these are hallmark signs of a patent ductus arteriosus. The other options—cyanosis, decreased urine output, and bradycardia—are either not typical of PDA or suggest complications not directly associated with the early stages of this condition.

Correct Answer: History of breast cancer

Explanation

A history of breast cancer is an absolute contraindication to menopausal hormone therapy (HT). Estrogen, especially when used in combination with progestin, can stimulate the growth of hormone receptor–positive breast cancer cells. For this reason, HT is contraindicated in women with a personal history of breast cancer, regardless of how long ago the cancer was treated or whether the patient is currently in remission. Alternative non-hormonal treatments for menopausal symptoms should be considered in these patients.

Why other options are wrong

history of dermatitis:

is not a contraindication to menopausal hormone therapy. While certain skin conditions may require careful management, they do not pose a risk related to hormone use. HT can still be safely used in clients with dermatitis if otherwise appropriate.

Multiple hospitalizations for COPD:

While multiple hospitalizations for COPD may indicate a chronic pulmonary disease, this alone is not a contraindication to hormone therapy. However, the overall cardiovascular and thromboembolic risk should be assessed, as HT may increase the risk of venous thromboembolism (VTE), particularly in women with other risk factors. Still, COPD by itself does not absolutely contraindicate HT use.

Concurrent treatment for GERD:

Concurrent treatment for GERD (gastroesophageal reflux disease) is also not a contraindication to HT. GERD is a common gastrointestinal condition and does not interact directly with hormone replacement therapy in a way that would necessitate avoidance.

Summary:

The correct answer is B. History of breast cancer, because hormone therapy can stimulate the growth of hormone-sensitive cancer cells and is therefore contraindicated. The other options — dermatitis, COPD, and GERD — are not contraindications to HT use and do not warrant automatic exclusion from this treatment approach.

Correct Answer: Gradual weaning of breastfeeding

Explanation:

Gradual weaning of breastfeeding (Correct):

Gradually weaning from breastfeeding is not a direct cause of mastitis. In fact, gradual weaning is often recommended as it helps prevent complications like engorgement or sudden milk stasis. Mastitis is more commonly caused by issues such as infrequent feedings, cracked nipples, or engorgement. A sudden cessation or abrupt weaning may increase the risk of milk stasis, but gradual weaning itself is not a typical cause.

Why other options are incorrect

Infrequent, inconsistent feedings (Incorrect):

Infrequent or inconsistent feedings can lead to milk stasis, which increases the risk of mastitis. When the milk isn't emptied properly from the breasts, it can become stagnant, leading to an infection in the breast tissue. This is a common cause of mastitis.

Cracks or fissures of the nipples (Incorrect):

Cracks or fissures in the nipples are a common cause of mastitis because they can provide an entry point for bacteria, leading to infection. Proper latch and nipple care are essential to prevent this.

Engorgement from oversupply of milk (Incorrect):

Engorgement occurs when there is an oversupply of milk, and it can lead to mastitis. When the breasts are not emptied properly, milk can accumulate, leading to swelling, pain, and a higher risk of infection.

Summary:

The correct answer is B. Gradual weaning of breastfeeding because this is not typically a direct cause of mastitis. The other options, such as infrequent feedings, cracked nipples, and engorgement, can contribute to mastitis due to milk stasis or infection risk

Correct Answer: Document the findings and continue to monitor the client.

Explanation

A large amount of lochia rubra with a few small clots is generally expected within the first 1 to 2 hours following delivery. Lochia rubra is the initial postpartum vaginal discharge and consists of blood, decidual tissue, and mucus. It is typically bright red and may contain small clots, especially when the client has been lying down and then gets up.

The fundus being firm, midline, and at the level of the umbilicus is a reassuring sign that the uterus is well-contracted, which reduces the risk of excessive bleeding or postpartum hemorrhage. Since the uterus is firm and there are no signs of abnormal bleeding (e.g., saturation of a pad in 15 minutes, large clots larger than a golf ball, boggy fundus, or signs of hypovolemia), the appropriate action is to document the findings and continue to monitor for any changes. No immediate interventions are necessary at this time.

Why other options incorrect:

Notify the provider immediately: Notify the provider immediately is not warranted unless there are signs of abnormal bleeding, uterine atony, or unstable vital signs. The current findings are within normal postpartum expectations.

Increase the frequency of fundal massage: Increase the frequency of fundal massage is unnecessary because the fundus is already firm and well-contracted. Excessive fundal massage can cause uterine irritation or lead to uterine inversion if done improperly or too aggressively.

Encourage the client to empty her bladder.: Encourage the client to empty her bladder is an important nursing intervention if the fundus is deviated from the midline or not firm, which can indicate a full bladder interfering with uterine contraction. However, in this scenario, the fundus is midline and firm, so bladder distention is not the issue.

Summary:

Option C is correct because the assessment findings—lochia rubra with small clots, a firm midline fundus at the umbilicus—are normal for 1 hour postpartum. There are no signs of complications, so the nurse should document and continue regular monitoring. The other options involve unnecessary or inappropriate interventions for this clinical presentation.

Correct Answer: Massage the fundus until it firms

Explanation :

After delivery, the fundus should be firm and contracted to prevent postpartum hemorrhage. If the fundus is soft and spongy, it indicates that the uterus is not contracting effectively, which can lead to increased bleeding. The first step in management is to massage the fundus to stimulate uterine contraction. This will help the uterus firm up and reduce the risk of hemorrhage. Massage should be done in a gentle but firm manner to encourage the uterus to contract.

Why the Other Options Are Incorrect:

Document the fundal height and consistency :

While it is important to document the findings, it is not the first intervention. If the fundus is soft, immediate action needs to be taken (i.e., massaging the fundus) rather than just documenting the assessment.

Notify the healthcare provider :

Notifying the healthcare provider is important if the massage does not resolve the issue or if the bleeding increases, but it is not the first step. The nurse should first attempt to massage the fundus to address the issue directly.

Administer Oxytocin IV per MD orders :

Oxytocin is typically given to promote uterine contractions and help control bleeding. However, the first intervention for a soft and spongy fundus is to massage the uterus, which may be sufficient to firm the fundus. If massaging the fundus does not work, then medication such as Oxytocin can be considered, but it should not be the first action.

Summary:

The first intervention when assessing a soft and spongy fundus postpartum is to massage the fundus until it firms (C). This will help stimulate uterine contractions and prevent potential complications like postpartum hemorrhage. Documenting, notifying the provider, and administering medication are important actions but should follow after the initial intervention.

Correct Answer: This position prevents stomach juice from going into the lungs

Explanation

In an infant with a tracheoesophageal fistula (TEF), there is an abnormal connection between the trachea (windpipe) and the esophagus. This condition increases the risk of aspiration, where contents from the stomach can flow into the airway or lungs. Elevating the infant's head at a 45-degree angle helps to prevent gastric contents (such as stomach juice) from flowing into the lungs, reducing the risk of aspiration pneumonia and further respiratory complications. This positioning allows gravity to assist in keeping stomach contents down in the stomach, helping to protect the respiratory system.

Why other options are wrong

This position helps my baby breathe better by opening the lungs: Although the elevated position can assist with respiratory effort, its primary purpose in a newborn with TEF is to prevent aspiration of stomach contents. It does not directly affect the opening of the lungs or ease breathing, which is not the main concern with TEF at this stage.

 This position keeps pressure off the stomach: While positioning the infant might indirectly relieve some pressure on the stomach, the main reason for elevating the head is to prevent aspiration into the lungs, not to reduce pressure on the stomach.

 This position allows food to be easily digested by the stomach: While head elevation may help with digestion in some situations, the primary concern for an infant with TEF is preventing aspiration and protecting the lungs from gastric contents. This positioning is not specifically for digestion.

Summary

For an infant with tracheoesophageal fistula (TEF), positioning the infant with the head elevated at a 45-degree angle is crucial to prevent aspiration of gastric contents into the lungs, which could lead to severe respiratory complications. The primary goal of this positioning is to protect the respiratory system, not for digestion or lung expansion.

Correct Answer:

I play games with my child every day to keep them as independent as possible.

I use utensils with large, padded handles to help my child feed themselves more easily.

Explanation:

I play games with my child every day to keep them as independent as possible. (Correct):

Playing games with a child who has spastic cerebral palsy is important for encouraging motor skills development and promoting independence. It also supports emotional well-being, enhances social skills, and encourages the child to participate in daily activities, which is essential for their development. Engaging in interactive games tailored to the child’s abilities helps build self-confidence and independence.

I use utensils with large, padded handles to help my child feed themselves more easily.(Correct):

For a child with spastic cerebral palsy, assistive devices like utensils with large, padded handles are highly beneficial. These tools help improve grip and control for children who have difficulty with fine motor coordination. They help the child gain more independence during meals, which is crucial for self-care skills development.

Why the Other Options Are Incorrect:

I perform range of motion exercises every 4 hours to help prevent contractures. (Incorrect):

Range of motion (ROM) exercises are indeed important for preventing contractures and improving muscle flexibility. However, the frequency stated here is too high. Generally, ROM exercises for children with cerebral palsy should be done two to three times a day, not every 4 hours, as overdoing them could cause discomfort and muscle fatigue.

 I give my child carbidopa so that they will stop drooling (Incorrect):

Carbidopa is typically used in combination with levodopa for managing Parkinson's disease and dopamine-related motor symptoms, not specifically for drooling in cerebral palsy. The treatment for drooling in children with cerebral palsy may include the use of anticholinergic medications, such as scopolamine, sialogogues, or even botulinum toxin injections for excessive drooling, but carbidopa is not the appropriate treatment.

I limit my child's interactions with peers to avoid overstimulation and frustration. (Incorrect):

While it is important to avoid overstimulation, social interaction is a key part of a child's development. Limiting peer interactions may hinder social skills development and the opportunity to practice appropriate behaviors. Children with cerebral palsy benefit from interacting with peers in a controlled and supportive environment, as it aids in emotional development and can foster friendships and communication skills.

Summary:

Appropriate care for a child with spastic cerebral palsy involves encouraging independence through activities like playing games (A) and using assistive tools like large-handled utensils (C) to aid feeding. ROM exercises should be done with appropriate frequency, carbidopa is not used to treat drooling, and limiting peer interactions may be counterproductive.

Correct Answer:

Tachypnea

Wheezes or rales

Difficulty feeding infant

Edema in feet and legs

Explanation:

Tachypnea :

Tachypnea (rapid breathing) is a common sign of heart failure in infants or children. The body compensates for decreased oxygenation by increasing the respiratory rate.

Wheezes or rales :

Wheezes or rales (crackling sounds in the lungs) indicate pulmonary congestion, which is common in heart failure. Fluid backs up into the lungs when the heart cannot effectively pump blood, leading to respiratory symptoms.

Difficulty feeding infant :

Infants with heart failure often experience fatigue and difficulty feeding due to poor circulation and respiratory distress. This can lead to poor weight gain and dehydration

Edema in feet and legs :

Edema (swelling) in the feet, legs, or abdomen is common in heart failure due to fluid retention. The heart's reduced ability to pump blood effectively leads to fluid accumulation in the body's tissues.

Why other options are incorrect

Increased comfort laying down :

Infants or children with heart failure typically experience difficulty when lying down due to increased pressure on the lungs and difficulty breathing, not increased comfort. Orthopnea (discomfort or difficulty when lying flat) is common in heart failure.

Increased urine output :

In heart failure, there is usually decreased urine output, as the kidneys receive less blood flow due to the heart's reduced ability to pump blood effectively. This often leads to fluid retention.

Summary:

The correct answers are B. Tachypnea, D. Wheezes or rales, E. Difficulty feeding infant, and F. Edema in feet and legs, as these are indicative of heart failure in infants and children. Increased comfort laying down and increased urine output are not typical signs of heart failure and should be considered incorrect.