ATI LPN
ATI Pediatrics Test Bank
1. The healthcare provider is assessing a newborn for signs of hypoglycemia. Which finding is consistent with hypoglycemia?
- A. Jitteriness
- B. Flushed skin
- C. Quiet alert state
- D. Strong cry
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. A client is in labor, and a nurse observes late decelerations on the electronic fetal monitor. What should the nurse identify as the first action that the registered nurse should take?
- A. Assist the client into the left-lateral position
- B. Apply a fetal scalp electrode
- C. Insert an IV catheter
- D. Perform a vaginal exam
Correct answer: A
Rationale: Late decelerations indicate uteroplacental insufficiency. The initial action should be to assist the client into the left-lateral position to optimize maternal blood flow and oxygenation to the fetus, thereby improving uteroplacental blood flow and fetal oxygenation. This position helps reduce pressure on the vena cava, enhancing blood return to the heart and improving circulation to the placenta. Applying a fetal scalp electrode (Choice B) is not the first action indicated for late decelerations. Inserting an IV catheter (Choice C) and performing a vaginal exam (Choice D) are not primary interventions for addressing late decelerations related to uteroplacental insufficiency.
3. A nurse is monitoring a client who has been receiving intermittent enteral feedings. What should the nurse identify as an intolerance to the feeding?
- A. Increased appetite
- B. Nausea
- C. Weight gain
- D. Regular bowel movements
Correct answer: B
Rationale: Nausea is a common sign of intolerance to enteral feedings. When a client experiences nausea, it can indicate difficulty in tolerating the feeding formula. This intolerance may also manifest as vomiting and dumping syndrome. Choices A, C, and D are incorrect because increased appetite, weight gain, and regular bowel movements are not typical signs of intolerance to enteral feedings.
4. A nurse is caring for a client who has congestive heart failure. Which of the following prescriptions from the provider should the nurse anticipate?
- A. Call the provider if the client’s respiratory rate is less than 18/min
- B. Administer 500 mL IV bolus of 0.9% sodium chloride over 1 hour
- C. Administer enalapril 2.5 mg PO twice daily
- D. Call the provider if the client’s pulse rate is less than 80/min
Correct answer: C
Rationale: The correct answer is C. Enalapril is an ACE inhibitor commonly prescribed for clients with congestive heart failure to help reduce blood pressure and fluid overload. Option A is incorrect as in congestive heart failure, a lower respiratory rate could be a sign of worsening condition and needs immediate attention rather than waiting to call the provider. Option B is incorrect as administering a large IV bolus of sodium chloride could exacerbate fluid overload in a client with heart failure. Option D is incorrect as a pulse rate lower than 80/min may not necessarily indicate a problem in a client with congestive heart failure.
5. When ventilating an apneic 3-year-old child with a bag-valve mask device, what is the MOST important action to take?
- A. Avoid hyperventilation and ensure adequate chest rise.
- B. Squeeze the bag with both hands and use a pediatric mask.
- C. Immediately insert an oropharyngeal airway.
- D. Provide one breath every 3 to 5 seconds.
Correct answer: A
Rationale: When ventilating an apneic child, the most important action is to avoid hyperventilation and ensure adequate chest rise. Hyperventilation can lead to decreased cardiac output and increased intracranial pressure. Adequate chest rise confirms effective ventilation and minimizes the risk of complications. Choice B is incorrect because using both hands to squeeze the bag may not ensure proper ventilation and can lead to complications. Choice C is incorrect as inserting an oropharyngeal airway is not the initial action in ventilating an apneic child with a bag-valve mask. Choice D is incorrect as providing ventilations every 3 to 5 seconds may not be appropriate for effective ventilation in a pediatric patient.
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