ATI RN
NCLEX Pediatric Respiratory Nursing Questions Questions
Question 1 of 5
Which recommendation should the nurse make to a patient to assist in initiating the milk-ejection reflex?
Correct Answer: C
Rationale: The correct answer is C - Place the infant to the breast. This is because oxytocin, which causes the milk let-down reflex, increases in response to nipple stimulation. Placing the infant to the breast stimulates this reflex and helps initiate milk flow. The other options, such as wearing a firm bra, drinking fluids, and applying cool packs, do not directly stimulate the milk-ejection reflex.
Question 2 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 3 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 4 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.
Question 5 of 5
Grunting is produced by expiration against a partially closed glottis and is an attempt to maintain positive pressure in the airway for as long as possible. It is MOST commonly associated with which condition?
Correct Answer: D
Rationale: In this scenario, the correct answer is D) croup. Grunting is a symptom commonly associated with croup, a viral infection that causes inflammation and swelling of the upper airway, leading to airway obstruction. The grunting sound is produced when the child exhales against a partially closed glottis, which helps maintain positive pressure in the airway to keep it open. This mechanism is the body's way of compensating for the narrowed airway due to inflammation. Option A) epiglottitis is incorrect because in epiglottitis, the child typically presents with a sore throat, high fever, and difficulty swallowing, rather than the characteristic grunting seen in croup. Option B) hyaline membrane disease is a condition primarily affecting premature infants, characterized by respiratory distress due to immature lung development. Grunting is not a typical finding in this condition. Option C) asthma is a chronic respiratory condition characterized by reversible airway obstruction due to inflammation and bronchoconstriction. While wheezing is a common symptom in asthma, grunting is not a typical feature. Educationally, understanding the specific respiratory symptoms associated with different pediatric conditions is crucial for nurses taking the NCLEX exam and in clinical practice. Recognizing the unique signs and symptoms of croup, such as grunting, barking cough, and stridor, can help nurses provide prompt and appropriate care to pediatric patients with this condition. This knowledge aids in effective assessment, intervention, and communication with healthcare providers to ensure timely management and positive patient outcomes.