a nurse is assessing a newborn who is 10 hr old which of the following findings should the nurse report to the provider
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Nursing Elites

ATI LPN

PN ATI Capstone Maternal Newborn

1. A nurse is assessing a newborn who is 10 hours old. Which of the following findings should the nurse report to the provider?

Correct answer: B

Rationale: Nasal flaring can indicate respiratory distress in a newborn, which is a critical finding requiring immediate attention. This may suggest an issue with breathing or lung function. Reporting nasal flaring promptly allows the provider to assess and intervene to ensure the newborn's respiratory status is stable. Choices A, C, and D are within normal parameters for a 10-hour-old newborn and do not indicate an immediate concern. An axillary temperature of 36.5°C (97.7°F) is within the normal range for a newborn. A heart rate of 158/min is typical for a newborn, and one void since birth is an expected finding at this early stage.

2. A nurse is discussing immunity with a client who has received an immunization. The nurse should identify that an immunization functions as part of which of the following types of immunity?

Correct answer: C

Rationale: Immunizations provide acquired immunity. They work by introducing antigens into the body, which triggers the immune system to produce antibodies specific to that antigen. Choice A, 'Innate immunity,' refers to the natural defense mechanisms an organism is born with and does not involve immunizations. Choice B, 'Passive immunity,' is the transfer of pre-formed antibodies and does not involve immunizations. Choice D, 'Natural immunity,' is a general term that encompasses all immunity that is not acquired through deliberate immunization or passive transfer of antibodies.

3. A charge nurse is planning care for a group of patients on a med-surg unit. What task should the nurse delegate to an assistive personnel?

Correct answer: A

Rationale: The correct answer is A because assistive personnel can be assigned to measure and document urinary output, a routine task within their scope of practice. Administering medications (choice B) requires a higher level of training and should be done by licensed nurses. Reinforcing patient education (choice C) involves providing information and ensuring patient understanding, which is typically done by licensed healthcare providers. Initiating a care plan (choice D) involves critical thinking and assessment skills, which are beyond the scope of practice for assistive personnel.

4. A nurse is caring for a client with a new prescription for lisinopril. Which of the following should the nurse monitor?

Correct answer: A

Rationale: Corrected Rationale: Lisinopril is an ACE inhibitor commonly used to lower blood pressure. Monitoring blood pressure is crucial when initiating this medication to assess its effectiveness and potential side effects related to blood pressure regulation. Liver function monitoring is not typically required with lisinopril. While lisinopril can affect potassium levels, it is not the primary parameter to monitor when starting this medication. Heart rate monitoring is not a routine requirement when initiating lisinopril therapy.

5. A client who has been prescribed oral contraception receives education from a nurse. Which of the following client statements indicates a need for further education?

Correct answer: C

Rationale: The correct course of action after missing oral contraceptive pills depends on how many pills are missed. If three pills are missed, the client should not 'double up' but rather follow the manufacturer's instructions and use an alternative form of contraception until the next cycle. Taking too many pills at once increases the risk of side effects without restoring contraceptive protection. Choices A, B, and D demonstrate understanding of the correct actions to take after missing a pill or two, emphasizing the importance of not doubling up but following specific guidelines to maintain effectiveness and safety.

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