ATI RN
Pediatric Respiratory Assessment Nursing Questions
Question 1 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 2 of 5
As you receive a report, which assessment finding should you recognize as an indication of a vaginal laceration?
Correct Answer: C
Rationale: Lacerations of the birth canal should always be suspected if excessive bleeding continues when the fundus is firm. Bleeding from the genital tract often is bright red, in contrast to the darker red color of lochia. A firm fundus, pulse of 90 bpm, blood pressure of 110/78 mm Hg, and being medicated twice in one shift are common findings in the postpartum patient.
Question 3 of 5
How can nurses prevent evaporative heat loss in the newborn?
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 4 of 5
An infant at 39 weeks' gestation was just delivered; included in the protocol for a term infant is an initial blood glucose assessment. The nurse obtains the blood sample and the reading is 58 mg/dL. What is the priority nursing action based upon this reading?
Correct Answer: A
Rationale: A blood glucose reading of 58 mg/dL in a term infant is within the normal range (50 to 90 mg/dL). Therefore, the priority nursing action would be to document the finding in the newborn's chart. No further interventions or notifications are necessary as the glucose level is appropriate for a term infant.
Question 5 of 5
The nurse is assessing a newborn delivered 24 hours ago for jaundice. What is the best way to evaluate for this finding?
Correct Answer: A
Rationale: The best way to evaluate for jaundice in a newborn is by pressing the infant's skin over a firm surface, such as the end of the nose or the sternum. Jaundice is identified by the yellow color that remains when the skin is pressed and blanches. This method is effective in detecting jaundice, which becomes visible when the bilirubin level is greater than 5 mg/dL. The other choices are not appropriate methods for evaluating jaundice.