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

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?

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. A client is being assessed by a nurse who is 30 minutes postoperative following an arterial thrombectomy. Which of the following findings should the nurse report?

Correct answer: A

Rationale: Chest pain is a critical finding postoperatively, especially after an arterial thrombectomy, as it could indicate complications like myocardial infarction or pulmonary embolism. It requires immediate attention and further evaluation. Muscle spasms, cool moist skin, and incisional pain are important to assess but not as urgent as chest pain in this scenario.

3. A client requests the creation of a living will. Which of the following actions should the nurse take?

Correct answer: B

Rationale: When a client requests the creation of a living will, the nurse's priority is to evaluate the client's understanding of life-sustaining measures. This involves ensuring that the client comprehends the implications of various life-sustaining interventions and can make informed decisions about their care preferences in the event they are unable to communicate them later. It is crucial for the nurse to assess the client's comprehension to ensure that the living will accurately reflects the client's wishes and values.

4. A healthcare professional is assessing a client following a gunshot wound to the chest. For which of the following findings should the healthcare professional not monitor to detect a pneumothorax?

Correct answer: C

Rationale: Bradycardia, which is a slow heart rate, is not typically associated with a pneumothorax. In a pneumothorax, the presence of air in the pleural space can lead to lung collapse, causing symptoms such as tachypnea (rapid breathing), deviation of the trachea, and pleuritic pain. Monitoring for bradycardia may not be as relevant in this context as it is not a typical indicator of a pneumothorax.

5. The healthcare provider orders the administration of an ampicillin capsule TID p.o. The healthcare provider should give the medication...

Correct answer: A

Rationale: In medical abbreviations, 'TID' stands for 'ter in die,' which means three times a day, and 'p.o.' stands for 'per os,' which means orally. Therefore, the correct administration schedule for the ampicillin capsule is three times a day orally. Choices B, C, and D are incorrect because they do not align with the prescribed frequency or route of administration specified in the order.

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