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

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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 parents of a 2-month-old boy are concerned about spoiling their son by picking him up when he cries. What is the nurse's best response?

Correct answer: B

Rationale: Comforting and cuddling a 2-month-old baby when they cry helps build trust and security. At this age, responding to cries does not lead to spoiling, but rather supports healthy emotional development.

3. Clinical manifestations of sodium excess (hypernatremia) include which signs or symptoms?

Correct answer: D

Rationale: Hypernatremia often presents with dry, sticky mucous membranes due to dehydration. Hyperreflexia and abdominal cramps may also occur, but dry mucous membranes are more consistently observed in cases of sodium excess.

4. What is the most critical physiologic change required of newborns at birth?

Correct answer: A

Rationale: The correct answer is A: Transition from fetal to neonatal breathing. The onset of breathing is the most immediate and critical physiologic change required for the transition to extrauterine life. Factors that interfere with this normal transition increase fetal asphyxia, which is a condition of hypoxemia, hypercapnia, and acidosis. While body temperature maintenance, stabilization of fluid and electrolytes, and closure of fetal shunts in the heart are crucial changes in the transition to extrauterine life, breathing and the exchange of oxygen for carbon dioxide must take precedence as they are essential for newborn survival.

5. An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is which?

Correct answer: C

Rationale: Providing a simple explanation satisfies the child's curiosity and helps reduce any anxiety about the procedure.

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