ATI RN
NCLEX Pediatric Respiratory Nursing Questions Questions
Question 1 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 2 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.
Question 3 of 5
Which preterm infant should receive gavage feedings instead of bottle feedings?
Correct Answer: C
Rationale: Infants less than 34 weeks of gestation or those who weigh less than 1500g generally have difficulty with bottle-feeding. Gavage feedings should be initiated if the respiratory rate is above 60 breaths per minute. In this case, a sustained respiratory rate of 70 breaths per minute indicates the need for gavage feedings to ensure proper nutrition and avoid respiratory distress.
Question 4 of 5
An infant presents with lethargy in the newborn nursery on the second day of life. On further examination, vital signs are stable and muscle tone is slightly decreased, with sluggish reflexes noted. Other physical characteristics are noted as being normal. Lab tests reveal a decreased hematocrit and increased blood sugar. The nurse suspects that the infant may be exhibiting signs and symptoms of
Correct Answer: B
Rationale: The signs and symptoms described, such as lethargy, decreased muscle tone and reflexes, decreased hematocrit, hyperglycemia, and acidosis, are consistent with intraventricular hemorrhage (IVH) or periventricular hemorrhage (PIVH). If the infant had respiratory distress syndrome (RDS) or bronchopulmonary dysplasia (BPD), there would be more respiratory symptoms present. If the infant had retinopathy of prematurity (ROP), there would be signs and symptoms related to the eyes.
Question 5 of 5
While in utero, the fetus passes meconium. Based on this assessment, which nursing diagnosis takes priority for the newborn at birth?
Correct Answer: C
Rationale: The fetus passing meconium in utero indicates a high-risk labor and birth scenario, increasing the likelihood of meconium aspiration syndrome (MAS). Therefore, the priority nursing diagnosis is the risk for aspiration related to retained secretions, as airway complications take precedence in terms of nursing diagnosis and medical management.