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

ATI RN

ATI Exit Exam 180 Questions Quizlet

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

A. Feed the infant 30 ml (1 oz) of glucose water every 2 hours.
B. Keep the infant's head covered with a cap.
C. Ensure that the newborn wears a diaper.
D. Apply lotion to the newborn every 4 hours.

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 skin irritation during phototherapy. Choice A is incorrect as newborns should be breastfed or formula-fed, not given glucose water. Choice B is unnecessary and may interfere with the effectiveness of phototherapy. Choice D is inappropriate as lotions can interfere with the phototherapy and increase the risk of skin damage.

2. A client in active labor is being assessed by a nurse. Which of the following findings should the nurse report to the provider?

A. Contractions lasting 80 seconds.
B. FHR baseline of 170/min.
C. Early decelerations in the FHR.
D. Temperature of 37.4°C (99.3°F).

Correct answer: B

Rationale: The correct answer is B because a baseline FHR of 170/min indicates fetal tachycardia, which needs further evaluation. Choice A about contractions lasting 80 seconds is within the normal range for active labor. Choice C, early decelerations in the FHR, are generally considered benign and do not require immediate reporting. Choice D, a temperature of 37.4°C (99.3°F), falls within normal limits for a laboring client and does not warrant immediate reporting.

3. What is the most important nursing action for a patient post-surgery?

A. Monitor vital signs
B. Monitor the surgical site
C. Check blood pressure
D. Check oxygen saturation

Correct answer: A

Rationale: The most crucial nursing action for a patient post-surgery is to monitor vital signs. Monitoring vital signs helps in detecting early signs of complications such as hemorrhage, shock, or infection. While monitoring the surgical site is important for assessing wound healing and signs of infection, it is secondary to monitoring vital signs. Checking blood pressure and oxygen saturation are also important, but they are components of monitoring vital signs.

4. A nurse is caring for a client who is at 38 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?

A. Fetal heart rate of 110/min
B. 1+ pitting edema
C. Blood pressure 138/80 mm Hg
D. Urine output of 20 mL/hr

Correct answer: D

Rationale: The correct answer is D. Urine output less than 30 mL/hr indicates decreased kidney perfusion, which is a serious complication of preeclampsia. Reporting this finding is crucial for prompt intervention. Choices A, B, and C are not the priority as fetal heart rate of 110/min, 1+ pitting edema, and blood pressure of 138/80 mm Hg are within normal limits for a client with preeclampsia at 38 weeks of gestation.

5. How should fluid balance be assessed in a patient with heart failure?

A. Monitor daily weight
B. Monitor input and output
C. Check for edema
D. Monitor blood pressure

Correct answer: A

Rationale: In patients with heart failure, monitoring daily weight is the most accurate method for assessing fluid balance. Weight gain can indicate fluid retention, a common issue in heart failure patients. Monitoring input and output (B) is essential but may not always accurately reflect fluid balance. Checking for edema (C) is important as it can indicate fluid accumulation, but daily weight monitoring is more precise. Monitoring blood pressure (D) is important in heart failure management but does not directly assess fluid balance.