the nurse performs a physical assessment of a newborn it is most important for the nurse to report which of the following findings

ATI RN

ATI RN Custom Exams Set 4

1. During a physical assessment of a newborn, which of the following findings should the nurse prioritize reporting?

A. Head circumference of 40 cm
B. Chest circumference of 32 cm
C. Acrocyanosis and edema of the scalp
D. Heart rate of 160 bpm and respirations of 40/min

Correct answer: A

Rationale: The correct answer is A. A head circumference of 40 cm is abnormally large for a newborn and could indicate conditions like hydrocephalus or other abnormalities, making it a crucial finding to report. Choices B, C, and D are within normal parameters for a newborn and do not pose immediate concerns. Chest circumference of 32 cm is a normal finding. Acrocyanosis and edema of the scalp are common in newborns due to physiological adaptations. A heart rate of 160 bpm and respirations of 40/min may be within the normal range for a newborn.

2. Which hospital level is a 296-bed facility that is staffed and equipped to provide care for all categories of patients?

A. FSB
B. CSH
C. GH
D. FH

Correct answer: C

Rationale: The correct answer is "GH" (General Hospital), which is a 296-bed facility providing comprehensive care for all categories of patients. Choice A, FSB, is incorrect as it does not denote a hospital level. Choice B, CSH, is incorrect as it does not specify a 296-bed facility. Choice D, FH, is incorrect as it does not indicate a hospital level or capacity.

3. Which of the following statements does NOT apply to a nursing plan of care?

A. It contains short-term goals
B. It is developed by the patient's physician
C. It must be continually evaluated
D. It contains long-range goals

Correct answer: B

Rationale: The correct answer is B. A nursing plan of care is developed by the nursing staff, not the patient's physician. Choice A is correct as nursing plans of care typically include short-term goals to address immediate needs. Choice C is also accurate as nursing plans of care need to be continually evaluated and updated to ensure they are effective. Choice D is incorrect as nursing plans of care can contain long-range goals to provide a roadmap for the patient's overall care and recovery.

4. The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which data would cause the nurse to question administering the medication?

A. The client’s BP is 110/70
B. The client’s potassium level is 3.4 mEq/L
C. The client has a barky cough
D. The client’s apical pulse is 56

Correct answer: D

Rationale: The correct answer is D. A beta blocker should be withheld if the apical pulse is below 60, as it can further decrease the heart rate. Choice A is not a reason to question administering the medication as the blood pressure is within a normal range for a client with essential hypertension. Choice B is not directly related to the administration of a beta blocker. Choice C suggests a potential side effect of an ACE inhibitor, not a beta blocker.

5. Which of the following drugs contribute to peptic ulcers?

A. Antacids
B. Certain antibiotics
C. Cholesterol-lowering medications
D. Nonsteroidal anti-inflammatory drugs

Correct answer: D

Rationale: The correct answer is D: Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs are known to contribute to peptic ulcers by affecting the gastric mucosa. Choice A, Antacids, actually help to alleviate symptoms of peptic ulcers by neutralizing stomach acid. Choice B, Certain antibiotics, are used to treat H. pylori infections, a common cause of peptic ulcers. Choice C, Cholesterol-lowering medications, do not contribute to peptic ulcers.