a nurse is preparing to assess a 2 week old newborn which of the following actions should the nurse plan to take

ATI RN

ATI Fundamentals Proctored Exam

1. A healthcare professional is preparing to assess a 2-week-old newborn. Which of the following actions should the professional plan to take?

A. Obtain the newborn's body temperature using a tympanic thermometer.
B. FACES pain scale.
C. Auscultate the newborn's apical pulse for 60 seconds.
D. Measure the newborn's head circumference over the eyebrows and below the occipital prominence.

Correct answer: C

Rationale: Assessing the apical pulse in newborns is important to evaluate their cardiac function. The normal heart rate for a newborn is typically between 100-160 beats per minute. Auscultating the apical pulse for a full 60 seconds allows for an accurate assessment of the newborn's heart rate. This is a crucial component of the newborn assessment to ensure the baby's cardiovascular system is functioning within the expected range.

2. Which of the following is a sign or symptom of a hemolytic reaction to a blood transfusion?

A. Hemoglobinuria
B. Chest pain
C. Urticaria
D. Distended neck veins

Correct answer: A

Rationale: Hemoglobinuria is a characteristic sign of a hemolytic reaction to a blood transfusion. Hemolytic reactions can lead to the destruction of red blood cells, causing the release of hemoglobin into the urine, which presents as hemoglobinuria. Chest pain, urticaria, and distended neck veins are not specific signs of a hemolytic reaction and may be associated with other conditions or reactions.

3. When caring for a toddler with acute lymphocytic leukemia, in which of the following activities should the toddler participate?

A. Looking at alphabet flashcards.
B. Playing with a large plastic truck.
C. Using scissors to cut out paper shapes.
D. Watching a cartoon in the dayroom.

Correct answer: B

Rationale: Toddlers with acute lymphocytic leukemia may have compromised immune systems and need to avoid activities that increase infection risk. Playing with a large plastic truck is a safe and engaging activity that does not pose a high risk of infection. This choice also promotes physical activity and creativity, which are beneficial for a toddler's development during illness.

4. During a Romberg test, the patient is asked to assume which position?

A. Sitting
B. Standing
C. Genupectoral
D. Trendelenburg

Correct answer: B

Rationale: During a Romberg test, the patient is asked to stand with feet together and arms at the sides. The test evaluates proprioception and vestibular function by assessing the patient's ability to maintain balance with eyes closed. Asking the patient to stand helps to detect any balance issues or disturbances in the absence of visual input.

5. After routine patient contact, how long should hand washing last at least?

A. 30 seconds
B. 1 minute
C. 2 minutes
D. 3 minutes

Correct answer: A

Rationale: Proper hand washing for 30 seconds is recommended after routine patient contact as it effectively removes pathogens. This duration ensures thorough cleaning without excessive time consumption, promoting infection control and prevention.