a nursing instructor is demonstrating an assessment on a newborn using the ballard gestational assessment tool the nurse explains that which of the fo
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ATI Pediatrics Proctored Exam 2023 with NGN

1. When using the Ballard gestational assessment tool on a newborn, which of the following tests should be performed after the first hour of birth, allowing the newborn to recover from the stress of birth?

Correct answer: A

Rationale: The correct answer is Arm recoil. Arm recoil is slower in healthy but fatigued newborns after birth, making it best elicited after the first hour of birth when the baby has had time to recover from the stress of birth. This assessment helps evaluate neuromuscular maturity in newborns and is more accurate when performed after the initial recovery period. The other choices, Square window sign, Scarf sign, and Popliteal angle, are not specifically assessed using the Ballard gestational assessment tool and do not relate to the recovery period after birth.

2. The nurse is assessing a postpartum client's fundus. Where should the nurse expect to find the fundus 24 hours after delivery?

Correct answer: A

Rationale: After delivery, the fundus is expected to be at the level of the umbilicus 24 hours postpartum. This position indicates that the uterus is involuting properly. Assessing the fundal height helps monitor the progress of uterine involution and can identify any potential complications like postpartum hemorrhage.

3. Seizures in children MOST often result from:

Correct answer: C

Rationale: Seizures in children most often result from febrile seizures, which are triggered by an abrupt rise in body temperature. Febrile seizures are common in young children, especially between the ages of 6 months to 5 years, and are usually associated with viral infections that cause a sudden spike in body temperature. Choices A, B, and D are incorrect because while infections, inflammatory processes, and high temperatures can sometimes lead to seizures, the most common cause of seizures in children is an abrupt increase in body temperature, known as febrile seizures.

4. What should you do immediately upon delivery of a newborn's head?

Correct answer: D

Rationale: Upon delivery of a newborn's head, the priority is to clear the airway to ensure proper breathing. Suctioning the mouth takes precedence over suctioning the nose or other actions to prevent potential airway obstruction. Choice D is the correct answer as it addresses the immediate need to maintain a clear airway for the newborn. Choices A, B, and C are not the correct actions to take at this moment as they do not directly address the crucial need to establish a clear airway for the newborn.

5. What comment made by a parent of a 1-month-old would alert the nurse about the presence of a congenital heart defect?

Correct answer: B

Rationale: Observing a 1-month-old tiring out during feedings should alert the nurse to the possibility of a congenital heart defect. This symptom may indicate that the infant is expending excess energy to compensate for a heart issue, leading to fatigue during feeding. Choices A, C, and D do not directly relate to a congenital heart defect. Being always hungry, fussy, or sleeping a lot are not specific signs of a congenital heart defect in a 1-month-old.

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