ATI RN
Pediatric Respiratory Distress Nursing Interventions Questions
Question 1 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 2 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 3 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.
Question 4 of 5
An infant who eats very rapidly may experience problems with swallowing excessive air. What should the mother be instructed to do?
Correct Answer: D
Rationale: It is important to begin feeding the infant before they become too hungry to prevent them from eating rapidly and swallowing excessive air. This will help the infant eat at a slower rate and reduce the risk of problems. Using a nipple with a smaller hole will not address the underlying issue of rapid eating. Placing the infant on the abdomen after feeding is not recommended for safety reasons. Providing water between feedings is unnecessary for infants and can affect their hydration levels.
Question 5 of 5
A new mother is preparing for discharge from the birthing center and relays to the nurse her concerns about how she will handle the baby's episodes of crying. What is the nurse's best response?
Correct Answer: A
Rationale: The correct answer is A) "I hear your concern. Is there someone in the household who cannot tolerate hearing a baby cry?" This response demonstrates empathetic listening and addresses the mother's concerns while also assessing potential risks to the baby's well-being. Option B is incorrect as advising a parent to let a baby cry can lead to increased stress for both the baby and parent, and contradicts current evidence-based practices that emphasize responsive caregiving. Option C is incorrect as it oversimplifies the reasons for infant crying, which can be due to a variety of factors beyond hunger or gas. Suggesting that the mother modify her diet to reduce gas-producing foods is not appropriate advice in this context. In an educational context, it is important for nurses to support parents in understanding and responding to their baby's needs, especially in the context of infant crying, which can be distressing for both the baby and caregivers. Teaching parents about normal infant behavior, soothing techniques, and when to seek help can help promote a positive parent-child relationship and infant well-being.