the nurse is assessing a newborn for signs of hypoglycemia which finding is consistent with hypoglycemia
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ATI Pediatrics Test Bank

1. The healthcare provider is assessing a newborn for signs of hypoglycemia. Which finding is consistent with hypoglycemia?

Correct answer: A

Rationale: Jitteriness is a common clinical manifestation of hypoglycemia in newborns. It is important to recognize this sign promptly as it can indicate a potentially serious condition that requires immediate attention and intervention to prevent complications.

2. You have arrived for your shift on the children's ward and need to assess a 2-year-old who is accompanied by his father. Identify the appropriate strategy to successfully complete a focused assessment:

Correct answer: D

Rationale: Having the child sit in parent's lap can help reduce anxiety and allow for a more accurate assessment.

3. What action should you take if a newborn's heart rate is 50 beats/min?

Correct answer: D

Rationale: If a newborn's heart rate is below 60 beats per minute, the appropriate action is to start positive-pressure ventilations. Ventilations help deliver oxygen to the newborn's body and support respiratory function, which is critical in cases of bradycardia. Chest compressions are not recommended until the heart rate is below 60 despite adequate ventilation. Reassessment is essential but not the immediate action required in this scenario. Administering blow-by oxygen alone may not effectively address the underlying cause of bradycardia, making positive-pressure ventilations the priority intervention in this case.

4. Which behavior is most indicative that a 2-year-old is experiencing the initial phase of separation anxiety because his parents cannot stay all day at the hospital with him?

Correct answer: B

Rationale: The most indicative behavior of a 2-year-old experiencing the initial phase of separation anxiety due to parents not staying all day at the hospital is crying when his parents leave. This behavior is a common manifestation of separation anxiety in children, as they struggle with the absence of their primary attachment figures. Choices A, C, and D are less indicative because withdrawing from the nursing staff, lying quietly in bed, or crying when parents arrive do not specifically demonstrate the distress caused by separation from parents, which is the hallmark of separation anxiety in children.

5. What intervention should the nurse encourage for a postpartum client complaining of perineal pain?

Correct answer: A

Rationale: The correct intervention for perineal pain in a postpartum client is the use of ice packs for the first 24 hours. Ice packs help reduce swelling and discomfort in the perineal area, especially during the initial post-delivery period. Applying heat packs can exacerbate swelling and discomfort. Avoiding peri-bottles may lead to poor perineal hygiene. Using tampons is contraindicated postpartum as it increases the risk of infection.

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