ATI RN
NCLEX Pediatric Respiratory Nursing Questions Questions
Question 1 of 5
The nurse is performing a gestational age assessment on a newborn. Which characteristic indicates the greatest gestational maturity?
Correct Answer: B
Rationale: Peeling, cracking, dryness, and a few visible veins in the skin are signs of maturity in the newborn. Extended arms and legs are a sign of preterm infants. Few rugae on the scrotum indicate a younger age in the newborn. The arm being able to be positioned with the elbow beyond the midline of the chest is a result of the scarf sign and indicates a newborn of a younger age. Therefore, the presence of peeling and cracking of the skin indicates the greatest gestational maturity.
Question 2 of 5
A 38 weeks' gestation fetus is delivered via cesarean birth and transported to the newborn nursery in an isolette. Apgar scores were 8, 9, and 10. At this time, the infant is receiving an initial assessment in the newborn nursery. Which is the priority nursing diagnosis?
Correct Answer: C
Rationale: Delivery via cesarean birth may affect the newborn's ability to clear excess fluid secretions, posing a risk for ineffective airway clearance. The Apgar scores do not indicate immediate tissue perfusion issues or ineffective thermoregulation. There is no evidence of equipment malfunction at this point.
Question 3 of 5
Which clinical finding indicates a sign of illness in the newborn?
Correct Answer: D
Rationale: An axillary temperature greater than 38°C (100.4°F) in a newborn is a sign of illness and should be promptly evaluated by a healthcare provider. Yellow scaly lesions on the scalp, more than two soft stools per day, and regurgitating a small amount of feeding are generally normal findings in newborns. Monitoring for signs of illness is crucial for early detection and intervention.
Question 4 of 5
Which recommendation should the nurse make to a patient to assist in initiating the milk-ejection reflex?
Correct Answer: C
Rationale: The correct answer is C - Place the infant to the breast. This is because oxytocin, which causes the milk let-down reflex, increases in response to nipple stimulation. Placing the infant to the breast stimulates this reflex and helps initiate milk flow. The other options, such as wearing a firm bra, drinking fluids, and applying cool packs, do not directly stimulate the milk-ejection reflex.
Question 5 of 5
What is the most serious consequence of propping an infant's bottle?
Correct Answer: B
Rationale: Propping the bottle increases the likelihood of choking and aspiration if regurgitation occurs, which can be a life-threatening situation for the infant. While colic, dental caries, and ear infections are concerning, aspiration poses the most immediate danger to the infant's health and well-being. It is important to educate parents on the risks associated with propping bottles to ensure the safety of the child.