ATI RN
Pediatric Respiratory Assessment Nursing Questions
Question 1 of 5
Which situation would require the administration of Rho(D) immune globulin?
Correct Answer: A
Rationale: An Rh-negative mother delivering an Rh-positive baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated. The Rho(D) immune globulin works to destroy the fetal cells in the maternal circulation before sensitization occurs. When the blood types are alike as with mother Rh-negative, baby Rh-negative, no antibody formation would be anticipated. If the Rh-positive blood of the mother comes in contact with the Rh-negative blood of the infant, no antibodies would develop because the antigens are in the mother's blood, not the infant's.
Question 2 of 5
The nurse observes a patient on her first postpartum day sitting in bed while her newborn lies awake in the bassinet. Which action is most appropriate for the nurse to take at this time?
Correct Answer: A
Rationale: During the taking-in phase of maternal adaptation, in which the mother may be passive and dependent, the nurse should encourage bonding when the infant is in the quiet alert stage. This is done best by simply giving the baby to the mother. She learns best during the taking-hold phase. The woman is dependent and passive at this stage and may have difficulty making a decision. This is expected behavior during the taking-in phase; however, interventions that facilitate infant bonding can be taken.
Question 3 of 5
teaching regarding thrombus formation is unnecessary?
Correct Answer: D
Rationale: The correct answer is D because support stockings should be applied before the patient rises from bed in the morning to prevent venous congestion. Choices A, B, and C are incorrect as they do not address the prevention of thrombus formation. It is essential to educate the patient on proper measures to prevent thrombus formation, especially after childbirth when the risk is increased.
Question 4 of 5
Which temperature indicates the presence of postpartum infection?
Correct Answer: D
Rationale: A temperature elevation of greater than 38°C (100.4°F) on two postpartum days, not including the first 24 hours, signifies infection. 37.5°C (99.6°F) in the first 48 hours is expected due to dehydration. To be classified as an infection, the temperature needs to be greater than 38°C (100.4°F). An elevated temperature is anticipated in the first 24 hours after delivery, so it is not a definitive indicator of infection.
Question 5 of 5
Following a vaginal birth, a patient has lost a significant amount of blood and is starting to experience signs of hypovolemic shock. Which clinical signs would be consistent with this diagnosis?
Correct Answer: B
Rationale: The correct answer is B because in the early stages of hypovolemic shock, clinical signs include normal blood pressure, decreased pulse pressure, compensatory tachycardia, and pale, cool skin color. These signs indicate the body's compensatory response to the decreased blood volume. Other options such as a decrease in heart rate or flushed skin are not consistent with the diagnosis of hypovolemic shock.