ATI RN
Pediatric Respiratory Distress Nursing Interventions Questions
Question 1 of 5
A white blood cell (WBC) count of 35,000 cells/mm3 on the morning of the first postpartum day indicates
Correct Answer: A
Rationale: The correct answer is A) possible infection. A white blood cell count of 35,000 cells/mm3 on the first postpartum day is elevated and indicates a potential infection in the postpartum mother. In the context of postpartum care, such a high WBC count is concerning as it may signify an underlying infection, such as endometritis or mastitis. Option B) normal WBC limit is incorrect because a WBC count of 35,000 cells/mm3 is above the normal range, which typically falls between 4,500 to 11,000 cells/mm3. Option C) serious infection is not the most appropriate choice because while a high WBC count does indicate an infection, it does not necessarily mean the infection is serious. Further assessment and investigation are needed to determine the severity of the infection. Option D) suspicion of a sexually transmitted disease is also incorrect as a high WBC count is not specific to sexually transmitted diseases and is more indicative of a general infection or inflammatory process. Understanding the significance of laboratory values in the postpartum period is crucial for nurses caring for postpartum mothers. Elevated WBC counts should prompt further assessment, monitoring, and intervention to ensure timely and appropriate management of any underlying infection.
Question 2 of 5
Which clinical finding might indicate development of a DVT (deep vein thrombosis)?
Correct Answer: C
Rationale: In pediatric patients with respiratory distress, the development of a DVT is a serious complication that can occur due to factors such as immobility, dehydration, or the presence of central venous catheters. The clinical finding of stiffness in the right leg is indicative of a potential DVT because it suggests limited range of motion, swelling, and pain which are classic symptoms of a deep vein thrombosis. Option A, slow gait, is a non-specific finding that may be seen in various conditions and does not specifically point towards DVT. Option B, shuffling gait, is more indicative of neurological or musculoskeletal issues rather than DVT. Option D, leaning on husband for support, may indicate weakness or instability but is not a typical sign of DVT. Educationally, it is important for nurses caring for pediatric patients with respiratory distress to be aware of the risk factors and clinical manifestations of DVT. Prompt recognition of signs like stiffness in the leg can lead to early intervention and prevention of complications such as pulmonary embolism. Nurses should also focus on prevention strategies such as promoting mobility, hydration, and appropriate use of compression stockings to reduce the risk of DVT in these vulnerable patients.
Question 3 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 4 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 5 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.