ATI RN
Pediatric Nclex Practice Questions Questions
Question 1 of 5
What is the priority nursing intervention when caring for a neonate born with bladder exstrophy?
Correct Answer: C
Rationale: In caring for a neonate born with bladder exstrophy, the priority nursing intervention is to cover the defect with sterile plastic wrap (Option C). This is crucial to prevent infection and maintain a sterile environment for the exposed bladder tissue. By covering the defect, the nurse helps protect the vulnerable area from contamination and potential complications. Option A, measuring intake and output, while important in overall neonatal care, is not the priority in this situation. Inserting a Foley catheter (Option B) or palpating the bladder mass (Option D) can potentially cause harm or increase the risk of infection due to the exposed nature of the bladder exstrophy. Educationally, understanding the priority interventions in caring for neonates with specific conditions like bladder exstrophy is essential for pediatric nurses. It ensures they can provide safe and effective care, prioritizing actions that address immediate risks to the newborn's health and well-being. This case highlights the importance of infection prevention and sterile technique in neonatal nursing care.
Question 2 of 5
A newborn diagnosed with an omphalocele defect is admitted to the intensive care nursery. Which nursing action is appropriate based on the current data?
Correct Answer: A
Rationale: The correct answer is A) Placing the newborn on a radiant warmer. In the case of a newborn with an omphalocele defect, it is crucial to maintain the infant's body temperature due to the exposed abdominal organs. Placing the newborn on a radiant warmer helps to prevent hypothermia and promote thermoregulation, which is essential for the infant's overall well-being and recovery. Option B) Placing the newborn in an open crib is incorrect because it does not address the specific need for thermal regulation in a newborn with an omphalocele defect. Exposing the infant to an open environment without adequate warmth can lead to complications. Option C) Preparing the newborn for phototherapy is also incorrect as phototherapy is used to treat conditions like jaundice, which is not directly related to an omphalocele defect. Option D) Preparing the newborn for bottle-feeding is inappropriate at this point as the priority for a newborn with an omphalocele defect is to ensure proper temperature maintenance and medical management before considering feeding options. In a pediatric nursing context, understanding the specialized care needs of infants with congenital defects is crucial for providing safe and effective nursing care. This question highlights the importance of prioritizing immediate physiological needs, such as thermoregulation, in infants with specific medical conditions like an omphalocele defect.
Question 3 of 5
The nurse is unsuccessful in inserting a nasogastric tube for a newborn client. The nurse suspects the newborn has esophageal atresia/tracheoesophageal (EA/TE) fistula. Which nursing action is appropriate while waiting for the healthcare provider to further assess the neonate?
Correct Answer: A
Rationale: Positioning the newborn in a semi-Fowler position is appropriate as it helps prevent aspiration in suspected EA/TE fistula. This position helps reduce the risk of regurgitation and aspiration of gastric contents. Placing the newborn in a semi-Fowler position promotes the drainage of secretions and reduces the risk of complications while awaiting further assessment by the healthcare provider.
Question 4 of 5
A 4-year-old child is admitted to the hospital secondary to dehydration. Laboratory tests indicate a high hemoglobin and hematocrit, and the serum sodium is below normal levels. Which condition does the nurse suspect based on the current data?
Correct Answer: C
Rationale: The correct answer is hypotonic dehydration. The combination of high hemoglobin and hematocrit with low serum sodium indicates hypotonic dehydration. In this condition, there is an excess of solutes relative to water, leading to higher red blood cell concentration (elevated hemoglobin and hematocrit) and low serum sodium levels.
Question 5 of 5
The healthcare provider is caring for a child on bed rest who has severe edema in the left lower extremity due to blocked lymphatic drainage. Which nursing diagnosis would take priority?
Correct Answer: A
Rationale: The priority nursing diagnosis in this scenario is 'Risk for Impaired Skin Integrity' because severe edema in the left lower extremity can lead to compromised circulation and pressure ulcers, increasing the risk of skin breakdown and infection. Addressing and preventing impaired skin integrity is crucial for the child's overall health and well-being.