an infant with congestive heart failure is receiving diuretic therapy a nurse is closely monitoring the intake and output the nurse uses which most ap
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Nursing Elites

ATI LPN

ATI Pediatric Medications Test

1. An infant with congestive heart failure is receiving diuretic therapy. A nurse is closely monitoring the intake and output. The nurse uses which most appropriate method to assess the urine output?

Correct answer: A

Rationale: Weighing the diapers is the most appropriate method to assess urine output in infants. Diapers will absorb and retain urine, providing a measurable indicator of urine output without invasive procedures. This method is non-invasive, simple, and convenient for monitoring urine output, especially in infants who may not be able to use other urine output measurement techniques. Inserting a Foley catheter is invasive and not indicated for routine urine output monitoring in infants. Comparing intake with output does not directly measure urine output. Measuring the amount of water added to formula does not provide an accurate assessment of urine output.

2. In contrast to the contractions associated with true labor, Braxton-Hicks contractions:

Correct answer: C

Rationale: Braxton-Hicks contractions are irregular and usually do not increase in intensity. Unlike true labor contractions, they tend to alleviate with a change in position, making option C the correct choice. Choices A, B, and D are incorrect because Braxton-Hicks contractions do not follow rupture of the amniotic sac, are not intensified by activity or accompanied by a pink discharge, and do not consistently become stronger or are not alleviated by changing position.

3. Following the initial steps of resuscitation, a newborn remains apneic and cyanotic. What should you do next?

Correct answer: A

Rationale: If a newborn remains apneic and cyanotic after the initial resuscitation steps, the next appropriate action is to begin ventilations with a bag-mask device. This helps provide oxygen to the newborn and can be crucial in supporting their respiratory efforts. Option B of flicking the soles of their feet is not recommended in this scenario as the priority is addressing the respiratory distress. Option C of suctioning their mouth and nose is not the immediate next step if the newborn is not spontaneously breathing. Option D of starting CPR based only on the heart rate is not the first-line intervention for an apneic and cyanotic newborn.

4. You are assessing a 26-year-old woman who is 38 weeks pregnant and is in labor. She tells you that she was pregnant once before but had a miscarriage at 19 weeks. You should document her obstetric history as:

Correct answer: B

Rationale: In obstetrics, gravida indicates the number of pregnancies, including the current one. Para indicates the number of pregnancies carried to viability (20 weeks or more). Since the patient has been pregnant twice but only carried one pregnancy past 20 weeks, her obstetric history should be documented as gravida 2, para 0. The miscarriage at 19 weeks does not contribute to the para count. Choice A (gravida 2, para 1) would indicate that she has had two pregnancies with one resulting in a live birth, which is incorrect. Choice C (gravida 1, para 1) would indicate that she has had one pregnancy with one live birth, which does not reflect her obstetric history. Choice D (gravida 0, para 2) would indicate that she has never been pregnant past 20 weeks, which is also inaccurate.

5. Nana Esi is an 11-year-old girl diagnosed with type 1 diabetes mellitus (DM). She asks her attending nurse why she can't take a pill rather than shots like her grandmother does. Which of the following would be the nurse's best reply?

Correct answer: C

Rationale: The nurse's best reply to Nana Esi is option C: 'Your body does not make insulin, so the insulin injections help to replace it.' In type 1 diabetes, the body's immune system destroys the insulin-producing beta cells in the pancreas. As a result, individuals with type 1 diabetes do not produce insulin, necessitating insulin injections for survival. Option A is incorrect as type 1 diabetes always requires insulin therapy. Option B is inaccurate as pills do not replace the function of insulin. Option D is also incorrect as there is no age restriction on using insulin therapy for type 1 diabetes.

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