ATI RN
NCLEX Pediatric Respiratory Nursing Questions Questions
Question 1 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 2 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 3 of 5
In providing and teaching cord care, which guidance is most appropriate?
Correct Answer: D
Rationale: The correct answer is D because keeping the umbilical cord dry helps decrease bacterial growth, as bacteria thrive in moist environments. Evidence-based practice recommends cleaning the cord with water when necessary and keeping it clean and dry for optimal care. No additional agents are needed for cord care, and the cord typically falls off within 10 to 14 days.
Question 4 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 5 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.