ATI RN
Pediatric Respiratory Assessment Nursing Questions
Question 1 of 5
The nurse observes a patient on her first postpartum day sitting in bed while her newborn lies awake in the bassinet. Which action is most appropriate for the nurse to take at this time?
Correct Answer: A
Rationale: During the taking-in phase of maternal adaptation, in which the mother may be passive and dependent, the nurse should encourage bonding when the infant is in the quiet alert stage. This is done best by simply giving the baby to the mother. She learns best during the taking-hold phase. The woman is dependent and passive at this stage and may have difficulty making a decision. This is expected behavior during the taking-in phase; however, interventions that facilitate infant bonding can be taken.
Question 2 of 5
Which temperature indicates the presence of postpartum infection?
Correct Answer: D
Rationale: A temperature elevation of greater than 38°C (100.4°F) on two postpartum days, not including the first 24 hours, signifies infection. 37.5°C (99.6°F) in the first 48 hours is expected due to dehydration. To be classified as an infection, the temperature needs to be greater than 38°C (100.4°F). An elevated temperature is anticipated in the first 24 hours after delivery, so it is not a definitive indicator of infection.
Question 3 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 4 of 5
As you receive a report, which assessment finding should you recognize as an indication of a vaginal laceration?
Correct Answer: C
Rationale: Lacerations of the birth canal should always be suspected if excessive bleeding continues when the fundus is firm. Bleeding from the genital tract often is bright red, in contrast to the darker red color of lochia. A firm fundus, pulse of 90 bpm, blood pressure of 110/78 mm Hg, and being medicated twice in one shift are common findings in the postpartum patient.
Question 5 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.