ATI RN
Pediatric Respiratory Assessment Nursing Questions
Question 1 of 5
Following a vaginal birth, a patient has lost a significant amount of blood and is starting to experience signs of hypovolemic shock. Which clinical signs would be consistent with this diagnosis?
Correct Answer: B
Rationale: The correct answer is B because in the early stages of hypovolemic shock, clinical signs include normal blood pressure, decreased pulse pressure, compensatory tachycardia, and pale, cool skin color. These signs indicate the body's compensatory response to the decreased blood volume. Other options such as a decrease in heart rate or flushed skin are not consistent with the diagnosis of hypovolemic shock.
Question 2 of 5
How can nurses prevent evaporative heat loss in the newborn?
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 3 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 4 of 5
The nurse is assessing a newborn delivered 24 hours ago for jaundice. What is the best way to evaluate for this finding?
Correct Answer: A
Rationale: The best way to evaluate for jaundice in a newborn is by pressing the infant's skin over a firm surface, such as the end of the nose or the sternum. Jaundice is identified by the yellow color that remains when the skin is pressed and blanches. This method is effective in detecting jaundice, which becomes visible when the bilirubin level is greater than 5 mg/dL. The other choices are not appropriate methods for evaluating jaundice.
Question 5 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.