ATI RN
NCLEX Pediatric Respiratory Nursing Questions Questions
Question 1 of 5
The nurse should expect medical intervention for subinvolution to include
Correct Answer: D
Rationale: In the context of pediatric respiratory nursing, understanding the management of subinvolution is crucial. Subinvolution refers to the failure of the uterus to return to its normal size after childbirth. In this scenario, the correct answer is D) oral methylergonovine maleate (Methergine) for 48 hours. Methylergonovine maleate is a medication commonly used to treat uterine atony, which is a common cause of postpartum hemorrhage. In cases of subinvolution, where the uterus fails to contract properly and return to its pre-pregnancy size, Methergine helps by promoting uterine contractions to reduce bleeding and aid in involution. Option A) oral fluids to 3000 mL/day is not directly related to the treatment of subinvolution. While hydration is important postpartum, it does not address the underlying issue of uterine subinvolution. Option B) intravenous fluid and blood replacement may be necessary in cases of postpartum hemorrhage due to subinvolution, but it does not specifically target the uterine contractions needed to address subinvolution. Option C) oxytocin intravenous infusion for 8 hours is commonly used to induce or augment labor contractions, but in cases of subinvolution, Methergine is more appropriate as it directly targets uterine contractions to address the issue. Educationally, this question highlights the importance of understanding pharmacological interventions in managing postpartum complications like subinvolution. Nurses must be able to differentiate between various medications and their specific indications to provide safe and effective care to postpartum patients.
Question 2 of 5
If a late postpartum hemorrhage is documented on a patient who delivered 3 days ago, the nurse recognizes that this hemorrhage occurred
Correct Answer: D
Rationale: The correct answer is D) on the second postpartum day. In the postpartum period, a late postpartum hemorrhage is defined as excessive bleeding occurring between 24 hours and up to 12 weeks post-delivery. In this scenario, since the patient delivered 3 days ago, the hemorrhage occurring on the second postpartum day aligns with this definition. Option A) on the first postpartum day is incorrect because a hemorrhage occurring on the first day would be considered an early postpartum hemorrhage, typically within the first 24 hours post-delivery. Option B) during the recovery phase of labor is incorrect as hemorrhage during labor recovery is not termed as postpartum hemorrhage. Option C) during the third stage of labor is also incorrect as this stage includes the delivery of the placenta, not the postpartum period. Educationally, understanding the timing and definitions of postpartum hemorrhage is crucial for nurses caring for postpartum patients. This knowledge is vital for early recognition, prompt intervention, and ensuring optimal outcomes for both the mother and baby. Nurses must be able to differentiate between early and late postpartum hemorrhage to provide appropriate care and prevent complications.
Question 3 of 5
To prevent infection of the reproductive tract, the nurse should instruct the patient to
Correct Answer: B
Rationale: Instructing the patient to cleanse the perineum from front to back helps prevent infection of the reproductive tract by avoiding introduction of infection from the anal area. Changing the peripad once per shift and performing pericare twice in a shift are incorrect as hygiene measures should be done at every voiding or bowel elimination. Increasing fluid intake does not directly prevent infection of the reproductive tract.
Question 4 of 5
The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as
Correct Answer: C
Rationale: Conjugation of bilirubin is the process of changing bilirubin from a fat-soluble to a water-soluble product. This process is important for the elimination of bilirubin from the body. The other choices, such as albumin binding, enterohepatic circuit, and deconjugation of bilirubin, do not describe the specific process of changing bilirubin's solubility.
Question 5 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.