ATI RN
Pediatric Respiratory Assessment Nursing Questions
Question 1 of 5
An infant at 39 weeks' gestation was just delivered; included in the protocol for a term infant is an initial blood glucose assessment. The nurse obtains the blood sample and the reading is 58 mg/dL. What is the priority nursing action based upon this reading?
Correct Answer: A
Rationale: A blood glucose reading of 58 mg/dL in a term infant is within the normal range (50 to 90 mg/dL). Therefore, the priority nursing action would be to document the finding in the newborn's chart. No further interventions or notifications are necessary as the glucose level is appropriate for a term infant.
Question 2 of 5
The parents require further teaching if they suggest that congenital hypothyroidism is not screened. The newborn screening tests are performed at 24 to 48 hours after birth. Newborn screening requires a blood sample taken from the infant's heel, and only one blood sample is needed for all tests. Tests performed within the first 24 hours of life are less sensitive than those performed after 24 hours. Infants tested before 12 to 24 hours of age should have repeat tests at 1 to 2 weeks of age so that disorders are not missed because of early testing.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 3 of 5
Which intervention will be most helpful to parents in identifying problems with an infant car seat?
Correct Answer: C
Rationale: The correct answer is C because observing the parents demonstrate the use of the car seat is the best way to identify any problems or misunderstandings. This allows for a hands-on assessment of their understanding. Questioning the parents may not reveal actual issues, providing laws does not ensure understanding, and allowing questions without a demonstration may not address potential errors. A return demonstration ensures comprehension and application of car seat safety.
Question 4 of 5
The nurse is calling a new mother to schedule a routine home visit planned for 48 to 72 hours after discharge. What is the nurse's priority question to help determine the best time for the visit?
Correct Answer: C
Rationale: The priority question is to determine when the mother will be nursing the baby to observe a feeding session, especially if she is breastfeeding. This helps assess milk supply, adequacy of breastfeeding, and provide support. The other options are not as crucial for determining the best time for the visit.
Question 5 of 5
What should the new breastfeeding mother be instructed to do?
Correct Answer: D
Rationale: Engorgement occurs when the breasts are not adequately emptied at each feeding or if feedings are not frequent enough. Breast milk moves through the stomach within 1.5 to 2 hours, therefore waiting 4 hours to feed is too long. Frequent feedings are important to empty the breast and establish lactation. Fluid intake should not be limited with a breastfeeding mother; that would decrease the amount of breast milk produced. Warm packs should be applied to the breast before feedings.