a nurse is assessing a newborn and notes that the infant has yellow tinged skin which of the following is the priority nursing action
Logo

Nursing Elites

ATI LPN

PN ATI Capstone Maternal Newborn

1. A nurse is assessing a newborn and notes that the infant has yellow-tinged skin. Which of the following is the priority nursing action?

Correct answer: A

Rationale: Yellow-tinged skin (jaundice) in a newborn can indicate hyperbilirubinemia. The priority action is to assess the infant's bilirubin levels to determine the severity of the jaundice and the need for further interventions, such as phototherapy. Initiating phototherapy (choice B) is premature without knowing the actual bilirubin levels. Monitoring the infant's temperature (choice C) is important but not the priority in this situation. Encouraging breastfeeding (choice D) is beneficial but not the priority when dealing with jaundice in a newborn.

2. A nurse is reviewing a prescription for doxazosin with a client. Which instruction should the nurse include?

Correct answer: C

Rationale: The correct answer is C: 'Rise slowly when sitting up.' Doxazosin can cause orthostatic hypotension, a sudden drop in blood pressure when standing up, leading to dizziness or fainting. Instructing the client to rise slowly helps prevent this adverse effect. Choices A, B, and D are incorrect. A decrease in caloric intake to reduce weight gain, an increase in dietary fiber to prevent constipation, and taking the medication each morning are not specific instructions related to managing the side effects of doxazosin.

3. A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation. Which of the following results should the nurse report to the provider?

Correct answer: D

Rationale: A platelet count of 140,000/mm³ is at the lower end of the normal range but can be concerning in pregnancy, especially if there are signs of thrombocytopenia or bleeding. Thrombocytopenia in pregnancy can lead to complications such as bleeding during childbirth or excessive bleeding postpartum. The other laboratory values mentioned are within normal ranges for pregnancy and do not typically raise immediate concerns. High WBC counts can be a normal response to pregnancy, hemoglobin levels around 11.2 g/dL and hematocrit levels around 34% are also considered normal in the third trimester.

4. A nurse is caring for a group of patients. Which of the following clients should the nurse refer to a social worker?

Correct answer: B

Rationale: The correct answer is B because social workers are involved in arranging care services like placement in assisted living facilities. This client's need for placement in an assisted living facility requires the expertise and assistance of a social worker. Choices A, C, and D do not necessarily require the intervention of a social worker. Choice A can be addressed by a nurse or healthcare provider, choice C can be managed by hospital staff or educators, and choice D may involve a nutritionist or community outreach programs.

5. A client receiving IV moderate (conscious) sedation with midazolam has a respiratory rate of 9/min and is not responding to commands. Which of the following is an appropriate action by the nurse?

Correct answer: D

Rationale: In this scenario, the client is showing signs of respiratory depression and central nervous system depression due to midazolam sedation. Administering flumazenil is the correct action as it is the antidote for midazolam, a benzodiazepine, and can reverse the sedative effects to restore respiratory function. Placing the client in a prone position (choice A) may worsen respiratory compromise. Implementing positive pressure ventilation (choice B) is not the first-line intervention for sedation-related respiratory depression. Performing nasopharyngeal suctioning (choice C) is not indicated as there are no signs of airway obstruction requiring suctioning.

Similar Questions

A nurse is providing teaching for a child who is prescribed ferrous sulfate. Which of the following instructions should the nurse include?
A nurse is providing teaching to a client who is at 34 weeks of gestation and is scheduled for a nonstress test. Which of the following statements should the nurse plan to make?
A school nurse is developing a teaching plan about testicular cancer for a group of adolescents. What information should the nurse include in the teaching?
A nurse is preparing to administer IV furosemide. Which of the following should the nurse monitor for during the infusion?
A healthcare professional is assessing the pain level of a client who has dementia and difficulty communicating. Which pain assessment technique should the healthcare professional use?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses