a nurse is caring for a newborn who was transferred to the nursery 30 min after delivery which of the following actions should the nurse take first a nurse is caring for a newborn who was transferred to the nursery 30 min after delivery which of the following actions should the nurse take first
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ATI LPN

Maternal Newborn ATI Proctored Exam 2023

1. A newborn was transferred to the nursery 30 min after delivery. What should the nurse do first?

Correct answer: B

Rationale: When a newborn is transferred to the nursery, the first action the nurse should take is to verify the newborn's identification. This step is crucial for ensuring the correct care is provided to the right newborn, promoting patient safety and preventing errors. Administering vitamin K (Choice C) is important but should not be the first action. Determining obstetrical risk factors (Choice D) is not the priority when the newborn is transferred to the nursery. Confirming (Choice A) and verifying (Choice B) have similar meanings, but 'verify' is a more appropriate term in this context.

2. What does the Tolerable Upper Intake Level (UL) represent?

Correct answer: D

Rationale: The Tolerable Upper Intake Level (UL) represents the highest amount of a nutrient that can be safely consumed without causing adverse health effects. It is not a replacement for Recommended Dietary Allowances (RDAs) (choice A) which are nutrient intake recommendations. While the UL is established to prevent toxicity, it is not a completely safe level for people of all ages (choice B). It is also not a potentially toxic level of intake of a nutrient (choice C), but rather the level that is unlikely to cause adverse health effects.

3. A healthcare provider is educating a patient about the side effects of selective serotonin reuptake inhibitors (SSRIs). Which side effect should the provider emphasize?

Correct answer: C

Rationale: When educating patients about SSRIs, it is crucial to emphasize the common side effect of nausea. Nausea is a frequently reported side effect of SSRIs that can impact adherence to treatment. By highlighting this side effect, patients can be better prepared and informed about what to expect when taking these medications. Choices A, B, and D are incorrect as weight gain, increased libido, and insomnia are not typically associated with SSRIs as common side effects. Nausea is a more relevant and prevalent side effect to address with patients.

4. The client with deep vein thrombosis (DVT) is receiving anticoagulant therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of the therapy?

Correct answer: B

Rationale: Activated partial thromboplastin time (aPTT) is the correct laboratory test to monitor the effectiveness of anticoagulant therapy, especially with heparin. A prolonged aPTT indicates effective anticoagulation, reducing the risk of further clot formation in the client with deep vein thrombosis (DVT). The other options, such as complete blood count (CBC), serum electrolytes, and liver function tests, do not directly assess the therapeutic effectiveness of anticoagulant therapy. Therefore, the correct answer is B.

5. How do you assess for dehydration in a pediatric patient?

Correct answer: A

Rationale: Correct! When assessing for dehydration in a pediatric patient, checking for dry mouth and decreased urine output are crucial indicators. Dry mouth indicates reduced fluid intake or dehydration, while decreased urine output suggests decreased renal perfusion secondary to dehydration. Skin turgor and capillary refill are more indicative of perfusion status rather than dehydration specifically. Lethargy and irritability can be present in dehydrated patients but are more general signs of illness. Monitoring blood pressure and heart rate are important in assessing dehydration severity but are not the initial signs used for assessment.

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