ATI RN
NCLEX Pediatric Respiratory Wong Nursing Questions Questions
Question 1 of 5
A patient with mastitis is concerned about breastfeeding while she has an active infection. Which is an appropriate response by the nurse?
Correct Answer: B
Rationale: The correct answer is B because the organisms that cause mastitis are localized in the breast tissue and are not passed through the breast milk to the infant. This means that the infant is not at risk of infection from breastfeeding during mastitis. While immunoglobulins in breast milk can protect infants from other infections, they do not protect against the specific organisms causing mastitis. Additionally, gastric acid does not inactivate these organisms.
Question 2 of 5
The nurse notes that the fundus of a postpartum patient is boggy, shifted to the left of the midline, and 2 cm above the umbilicus. What is the nurse's priority action?
Correct Answer: A
Rationale: The nurse's priority action when the fundus is not firm is to massage it until it becomes firm and to express any clots that may have accumulated. This helps the uterus contract effectively. Other actions such as assisting the patient to void, increasing oxytocin infusion, or bringing in a straight catheter tray are not the immediate priority in this situation.
Question 3 of 5
A newborn is admitted to the special care nursery with hypothermia. Which complication should the nurse monitor for closely?
Correct Answer: B
Rationale: Hypothermia can lead to metabolic acidosis in newborns. Cold stress increases oxygen demands and metabolism of glucose in the absence of sufficient oxygen can result in increased production of acids, leading to metabolic acidosis. Monitoring for metabolic acidosis is crucial in this scenario to prevent life-threatening complications. The other options, such as hyperglycemia, respiratory acidosis, and vasodilation of peripheral blood vessels, do not directly relate to the complication of hypothermia.
Question 4 of 5
Inspection of a newborn's head following birth reveals a hard ridged area and significant molding. The anterior and posterior fontanels show no sign of depression. Delivery history indicates that the mother was pushing for over 3 hours and had epidural anesthesia. A vacuum extraction was necessary. Based on this information the nurse would
Correct Answer: C
Rationale: The nurse should suspect craniosynostosis (premature closing of sutures) and therefore should contact the pediatric provider immediately. The physical findings do not align with a strenuous birth process, and monitoring is not the appropriate initial action. It is important to note the presence of fontanels, but the immediate action should be to seek medical intervention.
Question 5 of 5
Which of the following guidelines should the nurse implement to prevent the abduction of a newborn from the hospital?
Correct Answer: B
Rationale: The correct answer is B because questioning anyone seen walking in the hallways carrying an infant is a proactive measure to prevent newborn abduction. It is important to be vigilant and question individuals who do not have proper authorization or identification when carrying an infant. Restricting the time infants are out of the nursery and monitoring visitors are also important measures to prevent abduction.