a nurse is assessing a newborns heart rate which of the following actions should the nurse take
Logo

Nursing Elites

ATI RN

ATI Exit Exam RN

1. A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?

Correct answer: A

Rationale: Corrected Rationale: Auscultating the apical pulse and counting for one minute is the appropriate method to accurately measure a newborn's heart rate. The apical pulse is located at the point of maximum impulse (PMI), which is usually at the fourth or fifth intercostal space along the mid-clavicular line. This method allows for a precise assessment of the newborn's heart rate. Choice B, placing a sensor on the index finger, is incorrect because this method is more suitable for measuring oxygen saturation rather than heart rate. Choice C, heating the skin prior to placing the probe, is unnecessary for assessing heart rate and may lead to potential burns in newborns. Choice D, rechecking after 10 minutes, is not appropriate as immediate assessment and intervention may be required if an abnormal heart rate is detected in a newborn.

2. A nurse is caring for a client who is postoperative following an abdominal surgery. Which of the following assessments should the nurse prioritize?

Correct answer: B

Rationale: The correct answer is to monitor the client's respiratory rate. This assessment is crucial in the postoperative period to detect any respiratory complications such as hypoxia or respiratory distress. Assessing pain level (Choice A) is important but may not be the top priority as respiratory status takes precedence. Measuring blood pressure (Choice C) is also important but not as critical immediately postoperatively as monitoring respiratory function. Checking bowel sounds (Choice D) is relevant for assessing gastrointestinal function but is typically not the top priority in the immediate postoperative phase.

3. A client with heart failure is receiving a continuous IV infusion of milrinone. Which of the following actions should the nurse take?

Correct answer: D

Rationale: Measuring the client's intake and output every 2 hours is essential when caring for a client receiving a continuous IV infusion of milrinone. Milrinone is a medication that affects fluid balance, and monitoring intake and output helps assess the client's response to the medication. Continuous monitoring of blood pressure may not be necessary unless there is a specific indication. While weighing the client daily is important for overall assessment, measuring intake and output more frequently provides more real-time data for fluid balance evaluation. Monitoring the infusion site is crucial for detecting infiltration but is not directly related to managing fluid balance in this situation.

4. A nurse is caring for a client who has severe preeclampsia. Which of the following interventions should the nurse include in the plan of care?

Correct answer: C

Rationale: The correct intervention for a client with severe preeclampsia is to monitor intake and output. This is crucial to assess kidney function, fluid balance, and detect any signs of deterioration. Administering magnesium sulfate is indicated for seizure prophylaxis in severe preeclampsia, but it is not the primary intervention related to care planning. Placing the client in the left lateral position is not a specific intervention for managing preeclampsia. Providing a low-sodium diet is not typically recommended for clients with severe preeclampsia as sodium restriction is not a primary treatment modality for this condition.

5. A client is receiving opioid analgesics for pain management. Which of the following assessments is the priority?

Correct answer: C

Rationale: The correct answer is C: Monitor the client's respiratory rate. When a client is receiving opioid analgesics, the priority assessment is monitoring respiratory rate. Opioids can cause respiratory depression, so it is crucial to assess the client's breathing to detect any signs of respiratory distress promptly. Checking the client's blood pressure (Choice A) and urinary output (Choice B) are important assessments too, but they are not the priority when compared to ensuring adequate respiratory function. Assessing the client's pain level (Choice D) is essential for overall care but is not the priority assessment when the client is on opioids, as respiratory status takes precedence.

Similar Questions

How should a healthcare professional manage a patient with non-compliance to hypertension medication?
A client with a nasogastric tube receiving continuous enteral feedings is at risk for aspiration. Which of the following actions should the nurse take to prevent aspiration?
A nurse is caring for a client who is experiencing dysphagia. Which of the following interventions should the nurse implement?
A nurse is preparing to administer a blood transfusion to a client. Which of the following actions should the nurse take?
A nurse is observing bonding between the client and her newborn. Which of the following actions by the client requires the nurse to intervene?

Access More Features

ATI RN Basic
$69.99/ 30 days

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

ATI RN Premium
$149.99/ 90 days

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

Other Courses