the apnea monitor alarm sounds on a neonate for the third time during this shift what is the priority action by the nurse
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Nursing Elites

ATI RN

Nursing Care of Children ATI

1. The apnea monitor alarm sounds on a neonate for the third time during this shift. What is the priority action by the nurse?

Correct answer: D

Rationale: The priority action for the nurse when the apnea monitor alarm sounds on a neonate is to assess the infant for color and the presence of respirations. This initial assessment helps determine the infant's respiratory status and the need for immediate intervention. Providing tactile stimulation or administering oxygen should only be done after assessing the infant's respiratory status. Investigating possible causes of a false alarm comes after ensuring the infant's well-being through the initial assessment.

2. The nurse is performing an oral examination on a preschool child. Which strategies should the nurse use to encourage the child to open the mouth for the examination? (Select all that apply.)

Correct answer: D

Rationale: Using a cotton swab, allowing the child to observe, and demonstrating on someone else are effective ways to encourage a preschooler to open their mouth for examination.

3. Which nonpharmacologic intervention appears to be effective in decreasing neonatal procedural pain?

Correct answer: D

Rationale: Oral sucrose and nonnutritive sucking are effective nonpharmacologic interventions for reducing procedural pain in neonates.

4. The caregiver asks why the 6-month-old infant needs to have solid foods when breast milk is such a good source of nutrition. What would be the best response by the nurse?

Correct answer: A

Rationale: The correct response is A. Solid foods, especially iron-fortified cereals, are introduced to meet the infant's increased nutritional needs, including iron, which breast milk alone may not provide adequately. Choice B is incorrect because the extrusion reflex is related to the tongue-thrust reflex, not the nutritional needs of the infant. Choice C is incorrect as breastfeeding does not become painful when the infant gets more teeth, and it is not a reason for introducing solid foods. Choice D is incorrect as the infant's interest in trying new skills is not a primary reason for introducing solid foods at this age.

5. A nurse must do a venipuncture on a 6-year-old child. What consideration is important in providing atraumatic care?

Correct answer: B

Rationale: Showing the child the equipment before the procedure helps build trust and reduces fear. Using an 18-gauge needle is too large for a child, and multiple attempts can increase trauma. Restraining completely can increase fear and anxiety.

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