a nurse is caring for a 1 day old newborn who has jaundice and is receiving phototherapy which of the following actions should the nurse take a nurse is caring for a 1 day old newborn who has jaundice and is receiving phototherapy which of the following actions should the nurse take
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam

1. A nurse is caring for a 1-day-old newborn who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take is to ensure that the newborn wears a diaper. This is important to prevent irritation during phototherapy, as exposure to light can increase the risk of skin breakdown. Feeding the infant glucose water is unnecessary and not indicated for jaundice treatment. Keeping the infant's head uncovered allows the light to reach the skin effectively. Applying lotion to the newborn every 4 hours can interfere with the effectiveness of phototherapy and is not recommended.

2. The past history of Camila would most probably reveal that her premorbid personality is:

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

3. An infant has been diagnosed with failure to thrive (FTT) classified according to the pathophysiology of defective utilization. The nurse understands that the reason for the FTT is most likely related to what?

Correct answer: C

Rationale: FTT classified as defective utilization is often related to conditions like congenital infections, which interfere with the body's ability to effectively use nutrients. Conditions like cystic fibrosis and hyperthyroidism can also contribute to FTT but are categorized differently

4. A new mom is instructed to have her toddler brush his teeth every night after dinner. This is an example of __________ which increases the toddler’s sense of security and self-mastery.

Correct answer: D

Rationale: The correct answer is D, Ritualism. Establishing routines like brushing teeth every night after dinner helps toddlers feel secure and in control. Choice A, Negativism, refers to a child's oppositional behavior. Choice B, Diversionary activity, involves redirecting attention to something else. Choice C, Critical play, does not relate to the scenario of establishing a routine for the toddler.

5. The nurse is caring for a client on strict bed rest. Which intervention is the priority when caring for this client?

Correct answer: B

Rationale: The correct answer is to perform active range of motion exercises. When a client is on strict bed rest, performing range of motion exercises is a priority to prevent complications such as thromboembolism and muscle atrophy. Option A may be important but not the priority compared to maintaining mobility. Option C is incorrect because elevating the head of the bed to 45 degrees is not necessary for a client on strict bed rest. Option D, providing a high-fiber diet, is also not the priority intervention compared to ensuring range of motion exercises are performed.

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