ATI RN
NCLEX Pediatric Respiratory Nursing Questions Questions
Question 1 of 5
A 38 weeks' gestation fetus is delivered via cesarean birth and transported to the newborn nursery in an isolette. Apgar scores were 8, 9, and 10. At this time, the infant is receiving an initial assessment in the newborn nursery. Which is the priority nursing diagnosis?
Correct Answer: C
Rationale: Delivery via cesarean birth may affect the newborn's ability to clear excess fluid secretions, posing a risk for ineffective airway clearance. The Apgar scores do not indicate immediate tissue perfusion issues or ineffective thermoregulation. There is no evidence of equipment malfunction at this point.
Question 2 of 5
Which recommendation should the nurse make to a patient to assist in initiating the milk-ejection reflex?
Correct Answer: C
Rationale: The correct answer is C - Place the infant to the breast. This is because oxytocin, which causes the milk let-down reflex, increases in response to nipple stimulation. Placing the infant to the breast stimulates this reflex and helps initiate milk flow. The other options, such as wearing a firm bra, drinking fluids, and applying cool packs, do not directly stimulate the milk-ejection reflex.
Question 3 of 5
What is the most serious consequence of propping an infant's bottle?
Correct Answer: B
Rationale: Propping the bottle increases the likelihood of choking and aspiration if regurgitation occurs, which can be a life-threatening situation for the infant. While colic, dental caries, and ear infections are concerning, aspiration poses the most immediate danger to the infant's health and well-being. It is important to educate parents on the risks associated with propping bottles to ensure the safety of the child.
Question 4 of 5
Which preterm infant should receive gavage feedings instead of bottle feedings?
Correct Answer: C
Rationale: Infants less than 34 weeks of gestation or those who weigh less than 1500g generally have difficulty with bottle-feeding. Gavage feedings should be initiated if the respiratory rate is above 60 breaths per minute. In this case, a sustained respiratory rate of 70 breaths per minute indicates the need for gavage feedings to ensure proper nutrition and avoid respiratory distress.
Question 5 of 5
An infant presents with lethargy in the newborn nursery on the second day of life. On further examination, vital signs are stable and muscle tone is slightly decreased, with sluggish reflexes noted. Other physical characteristics are noted as being normal. Lab tests reveal a decreased hematocrit and increased blood sugar. The nurse suspects that the infant may be exhibiting signs and symptoms of
Correct Answer: B
Rationale: The signs and symptoms described, such as lethargy, decreased muscle tone and reflexes, decreased hematocrit, hyperglycemia, and acidosis, are consistent with intraventricular hemorrhage (IVH) or periventricular hemorrhage (PIVH). If the infant had respiratory distress syndrome (RDS) or bronchopulmonary dysplasia (BPD), there would be more respiratory symptoms present. If the infant had retinopathy of prematurity (ROP), there would be signs and symptoms related to the eyes.