ATI RN
Pediatric Emergency Nursing PICO Questions Questions
Question 1 of 5
The nurse is assessing a newborn who had undergone vaginal delivery. Which of the following findings is least likely to be observed in a normal newborn?
Correct Answer: D
Rationale: The heart rate of a normal newborn is typically 120 to 160 bpm. Therefore, a heart rate of 80 bpm would be least likely to be observed in a normal newborn. This finding may indicate bradycardia, which should be further evaluated and managed by the healthcare provider. Other options such as an uneven head shape, irregular respirations, (+) Moro reflex are common and expected in newborns.
Question 2 of 5
Which statement by the mother of an 18-month-old would lead the nurse to believe that the child should be referred for further evaluation for developmental delay?
Correct Answer: A
Rationale: By 15 to 18 months, most toddlers should be walking independently. An 18-month-old who is not yet walking warrants further evaluation.
Question 3 of 5
The nurse is conducting discharge teaching about signs and symptoms of heart failure to parents of an infant with a repaired tetralogy of Fallot. Which signs and symptoms should the nurse include? (Select all that apply.)
Correct Answer: C
Rationale: C. Decreased urinary output: This can be a sign of fluid retention, which is a common symptom of heart failure. Infants with heart failure may have decreased urine output as the body tries to retain fluid to help compensate for the heart's decreased ability to pump effectively.
Question 4 of 5
Wilma knew that James have an adequate respiratory condition if she notices that
Correct Answer: A
Rationale: An adequate respiratory condition can be indicated by a normal respiratory rate. The normal adult respiratory rate typically ranges from 12 to 20 breaths per minute. In this case, if James' respiratory rate is 18, it falls within the normal range and would suggest that his respiratory condition is adequate. Oxygen saturation levels and the presence of blood suction or secretions are important factors to consider as well, but directly assessing the respiratory rate provides a more immediate indication of respiratory status.
Question 5 of 5
Which of the following may be the first abnormal sign detected in a client with cardiomyopathy?
Correct Answer: C
Rationale: Dyspnea, or difficulty breathing, may be the first abnormal sign detected in a client with cardiomyopathy. Cardiomyopathy is a disease of the heart muscle, which can lead to impaired heart function. As the heart's ability to pump blood effectively is compromised, the body may not receive an adequate supply of oxygen-rich blood. This can result in symptoms such as dyspnea, especially during physical exertion or when lying down. Ascites (fluid accumulation in the abdomen), chest pain, and heart murmur may also be seen in clients with cardiomyopathy but are not typically the first signs to present. Dyspnea is often a key indicator that should prompt further evaluation and monitoring for cardiac issues.