ATI RN
Pediatric Respiratory Distress Nursing Interventions Questions
Question 1 of 5
A postpartum patient has developed deep vein thrombosis (DVT) and treatment with warfarin (Coumadin) has been initiated. Which dietary selection should be modified in view of this treatment regimen?
Correct Answer: C
Rationale: Foods that are high in vitamin K should be restricted and/or limited in consumption while on Coumadin therapy. Vitamin K is the antidote to Coumadin activity. Therefore, lentils, which are high in vitamin K, should be modified in the patient's diet to prevent interference with the effectiveness of warfarin in treating DVT.
Question 2 of 5
The nurse is explaining how a newly delivered baby initiates respirations. Which statement explains this process most accurately?
Correct Answer: B
Rationale: The correct answer is B) Chemical, thermal, and mechanical factors. This option accurately describes the process of how a newly delivered baby initiates respirations. Chemical factors include the increase in carbon dioxide and decrease in oxygen levels that occur during labor and delivery, stimulating the respiratory center in the brain to initiate breathing. Thermal factors refer to the change in temperature after birth, which also contributes to the initiation of respirations. Mechanical factors involve the physical stimulation of the baby, such as the pressure changes during birthing that help trigger the first breath. Option A) Drying off the infant is a common nursing intervention after birth to prevent heat loss, but it does not directly explain how a baby initiates respirations. Option C) An increase in the PO2 and a decrease in the PCO2 may be true after birth, but it does not fully capture the complex interplay of factors that initiate breathing in a newborn. Option D) The continued functioning of the foramen ovale is related to fetal circulation and not directly relevant to the initiation of respirations in a newborn. In an educational context, understanding the factors that initiate respirations in a newborn is crucial for nurses caring for neonates. By grasping the physiological processes involved, nurses can provide appropriate support and interventions to ensure the baby transitions smoothly to extrauterine life.
Question 3 of 5
During the first few minutes after birth, which physiologic change occurs in the newborn as a response to vascular pressure changes in increased oxygen levels?
Correct Answer: D
Rationale: In response to increased oxygen levels, a physiologic change in the newborn is the dilation of pulmonary vessels. This response helps facilitate the transition to breathing air. The other options do not accurately reflect the physiologic change associated with increased oxygen levels in the newborn.
Question 4 of 5
A yellow crust has formed over the circumcision site. The mother calls the hotline at the local hospital 5 days after her son was circumcised. She is very concerned. Which response by the nurse is most appropriate?
Correct Answer: A
Rationale: The correct answer is A because crusting is a normal part of healing after circumcision. It is important not to remove the yellow crust, as it is a natural part of the healing process. It is essential to differentiate between normal yellowish exudate and purulent drainage of infection. Discontinuing the use of petroleum jelly is not necessary unless a specific device was used for circumcision. Keeping the diaper loose is important to prevent rubbing or pressure on the incision site.
Question 5 of 5
A glucose level of 40 mg/dL requires an action. The nurse should follow agency policy and health care provider orders regarding feeding infants with low glucose levels. A common practice is to feed the newborn breast milk or formula if the glucose screening reveals a level of 40 to 45 mg/dL or less to prevent further depletion of glucose. Infants with severe hypoglycemia may need intravenous feedings to provide glucose.
Correct Answer: A
Rationale: The correct answer is A) Glucose level of 40 mg/dL. In pediatric respiratory distress scenarios, monitoring glucose levels is crucial as hypoglycemia can worsen the condition. A glucose level of 40 mg/dL indicates hypoglycemia, which can lead to brain damage if not promptly corrected. The action to feed breast milk or formula is essential to replenish glucose levels and prevent further depletion. Option B) Axillary temperature of 37°C is within the normal range for body temperature and does not require immediate intervention in this context. Option C) A mild yellow tinge to the skin at 32 hours of age suggests physiological jaundice, which is common in newborns and does not directly relate to the need for immediate glucose intervention. Educationally, understanding the significance of glucose levels in pediatric patients experiencing respiratory distress is crucial for nurses. Timely identification and appropriate management of hypoglycemia can significantly impact patient outcomes. Nurses need to be aware of agency policies and healthcare provider orders to provide effective care for infants in respiratory distress.