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: Failed to generate a rationale of 500+ characters after 5 retries.