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. A healthcare professional in the emergency department is assessing a client who has a suspected flail chest. Which of the following findings should the professional not expect?

A. Bradycardia
B. Cyanosis
C. Hypotension
D. Dyspnea

Correct answer: A

Rationale: Bradycardia is not typically associated with a flail chest. Flail chest is characterized by paradoxical chest wall movement, respiratory distress, and hypoxia, but it does not usually cause bradycardia. The other options, such as cyanosis (bluish discoloration of the skin due to poor oxygenation), hypotension (low blood pressure), and dyspnea (difficulty breathing), are commonly seen in patients with flail chest due to the underlying respiratory compromise.

3. 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.

4. Which of the following procedures always requires surgical asepsis?

A. Vaginal instillation of conjugated estrogen
B. Urinary catheterization
C. Nasogastric tube insertion
D. Colostomy irrigation

Correct answer: B

Rationale: Surgical asepsis, which involves maintaining a sterile field and preventing contamination in a surgical setting, is required for urinary catheterization as it involves entering a sterile body cavity. Vaginal instillation of conjugated estrogen, nasogastric tube insertion, and colostomy irrigation do not always require surgical asepsis as they involve different levels of sterility and infection control measures.

5. When caring for a client in the advanced stage of amyotrophic lateral sclerosis (ALS), which of the following referrals is the nurse's priority?

A. Psychologist
B. Social worker
C. Occupational therapist
D. Speech-language pathologist

Correct answer: D

Rationale: In the advanced stage of ALS, speech and swallowing difficulties become significant. As a result, the priority referral for the nurse would be a speech-language pathologist. This professional can assist in managing communication challenges and provide strategies to address swallowing issues, ensuring the client's safety and quality of life.