ATI RN
Pediatrics Baby Fell off Bed Questions Questions
Question 1 of 5
Which finding on a newborn assessment should the nurse recognize as suggestive of a clavicle fracture?
Correct Answer: C
Rationale: A newborn with a clavicle fracture may present with swelling of the fingers on the affected side. This is due to the injury disrupting the nerves and blood vessels that supply the arm, leading to edema and swelling in the fingers. The other signs mentioned in the options are not typically associated with a clavicle fracture. A negative scarf sign relates to positioning of the arm and is not specific to a clavicle fracture. Asymmetric Moro reflex can be a normal finding in newborns and not indicative of a fracture. Paralysis of the affected extremity and muscles would be more suggestive of a nerve injury rather than a clavicle fracture.
Question 2 of 5
Which is the central factor responsible for respiratory distress syndrome?
Correct Answer: A
Rationale: Respiratory distress syndrome is primarily caused by deficient surfactant production in premature infants. Surfactant is a substance that coats the alveoli in the lungs and helps to reduce surface tension, preventing the collapse of the alveoli during exhalation. In premature infants, the lungs may not have produced enough surfactant, leading to difficulty in breathing and inadequate oxygen exchange. This results in respiratory distress syndrome, which is characterized by severe breathing problems in newborns. Overproduction of surfactant, overdeveloped alveoli, or absence of alveoli are not central factors in the development of respiratory distress syndrome.
Question 3 of 5
The nurse needs to obtain blood for ongoing assessment of a high-risk newborn's progress. Which tests should the nurse monitor? (Select all that apply.)
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 4 of 5
The nurse must assess a 10-month-old infant. The infant is sitting on the father's lap and appears to be afraid of the nurse and of what might happen next. Which initial action by the nurse would be most appropriate?
Correct Answer: D
Rationale: Talking softly to the infant while taking him from his father would be the most appropriate initial action by the nurse in this situation. This approach allows the nurse to maintain communication with the infant to provide comfort and minimize fear or anxiety. By using a gentle tone and reassuring words, the nurse can help establish a sense of safety for the infant as he is transitioned from his father's lap to the examination table. This gradual and supportive approach is likely to facilitate a smoother assessment process and help build trust with the infant and the family.
Question 5 of 5
The nurse observes yellow staining in the sclera of eyes, soles of feet, and palms of hands. How should the nurse document these findings?
Correct Answer: C
Rationale: Jaundice is the yellow discoloration of the skin, sclera (white part of the eyes), soles of feet, and palms of hands that occurs due to elevated levels of bilirubin in the blood. Bilirubin is a yellow pigment produced during the breakdown of red blood cells and is normally processed by the liver and excreted in bile. When the liver is unable to process bilirubin effectively, it can accumulate in the blood and cause jaundice. Therefore, the nurse should document these findings as jaundice, which is a sign of liver dysfunction or other underlying health issues that need further assessment and management.