which is the priority nursing assessment when providing care for an infant at risk for dehydration which is the priority nursing assessment when providing care for an infant at risk for dehydration
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Nursing Elites

ATI RN

ATI Pediatrics Proctored Exam 2023

1. Which is the priority nursing assessment when providing care for an infant at risk for dehydration?

Correct answer: D

Rationale: The correct answer is Daily weight. Daily weight is a crucial assessment in infants at risk for dehydration because changes in weight can indicate fluid balance and dehydration status. It is essential to monitor daily weight to promptly identify and manage dehydration in infants.

2. Which of the following is the best available predictor of infant survival and healthy development?

Correct answer: D

Rationale: The correct answer is 'Birth weight.' Birth weight is a crucial indicator of an infant's chances of survival and well-being. Low birth weight is associated with various health risks and developmental challenges. Birth length (choice A) is not as significant in predicting infant outcomes as birth weight. The Combined Apgar score (choice B) is a measure of the newborn's health status at birth, not a predictor of long-term survival and development. Delivery date (choice C) is important for determining gestational age but is not as directly related to infant survival and healthy development as birth weight.

3. What time frame has the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) and American College of Obstetricians and Gynecologists recommended that pregnant adolescents and women who are not protected against pertussis receive the tetanus, diphtheria, and pertussis (Tdap) vaccine?

Correct answer: A

Rationale: The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) and American College of Obstetricians and Gynecologists recommend that pregnant adolescents and women without protection against pertussis should receive the Tdap vaccine ideally between 27 and 36 weeks of gestation or postpartum before discharge from the hospital. This timeframe allows for the development of antibodies in the mother to protect her and provide passive immunity to the infant. Administering the vaccine during the first trimester (Choice D) is not recommended as the optimal time is between 27 and 36 weeks. Choice B, during the first prenatal visit, is too early for optimal protection, and Choice C, 24 hours prior to delivery, does not provide enough time for the vaccine to be effective before birth.

4. A client reports difficulty sleeping while in the hospital. Which of the following actions taken by the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene?

Correct answer: B

Rationale: The correct answer is B because flushing the client's toilet after emptying the urinary catheter's drainage bag could disturb the client's rest. The nurse should intervene to ensure a restful environment for the client. Choices A, C, and D are not actions that would be disruptive to the client's sleep. Closing the door to the client's room, measuring vital signs routinely, and asking personnel in the hall to speak quietly are appropriate actions that do not directly disturb the client's rest.

5. What is the rationale in the use of bag technique during home visits?

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

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