a nurse is completing an assessment of a newborn who is 2 hours old which of the following findings are indicative of cold stress a nurse is completing an assessment of a newborn who is 2 hours old which of the following findings are indicative of cold stress
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PN ATI Capstone Proctored Comprehensive Assessment A

1. A nurse is completing an assessment of a newborn who is 2 hours old. Which of the following findings is indicative of cold stress?

Correct answer: B

Rationale: Jitteriness of the hands is a classic sign of cold stress in newborns, indicating that the infant is having difficulty maintaining a stable body temperature. Cold stress can lead to hypoglycemia and increased oxygen consumption. The other options (A, C, and D) are not directly associated with cold stress in newborns. A respiratory rate of 60 per minute may be within the normal range for a newborn. Diaphoresis (excessive sweating) and bounding peripheral pulses are not specific signs of cold stress in newborns.

2. A client is being treated for eclampsia. What is a priority nursing intervention?

Correct answer: A

Rationale: The correct answer is to 'Assess for hyperreflexia.' Eclampsia is a severe complication of pregnancy that involves seizures. Hyperreflexia, an overactive or overresponsive reflex, is often an early sign of impending eclampsia. By assessing for hyperreflexia, nurses can identify this warning sign and take preventive measures to manage the condition before seizures occur. Administering oxygen (Choice B) may be necessary but is not the priority in this situation. Monitoring blood pressure (Choice C) is important but assessing for hyperreflexia takes precedence as it can lead to immediate life-threatening complications. While preparing for delivery (Choice D) may ultimately be necessary, the immediate priority is to assess for hyperreflexia to prevent seizures.

3. A protein that contains all the essential amino acids in the proper proportions is called:

Correct answer: C

Rationale: A complete protein is the term used to describe a protein that contains all the essential amino acids required by the body in the right proportions. This makes choice C the correct answer. Choice A, 'simple,' is incorrect as it does not reflect the concept of essential amino acids. Choice B, 'indispensable,' while related to importance, does not specifically address the presence of all essential amino acids. Choice D, 'complementary,' is also incorrect as it refers to combining proteins to achieve a complete amino acid profile, rather than describing a protein that already contains all essential amino acids.

4. Which therapeutic communication technique is being used when the nurse says, 'Tell me more about what you are feeling right now'?

Correct answer: D

Rationale: The correct answer is D, Exploration. In this scenario, the nurse is using the exploration technique to encourage the patient to elaborate further on their feelings. Exploration involves prompting the patient to delve deeper into their thoughts and emotions, fostering a more comprehensive discussion and understanding of their experiences.

5. Which of the following is a characteristic of Primary Health Care?

Correct answer: B

Rationale: Primary Health Care is characterized by its emphasis on community participation, which involves active involvement of communities in health promotion, disease prevention, and healthcare decision-making. It is a comprehensive approach that encompasses preventive, promotive, curative, and rehabilitative services, aiming to provide accessible, affordable, and equitable healthcare to all individuals.

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