the apnea monitor alarm sounds on a neonate for the third time during this shift what is the priority action by the nurse
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Nursing Elites

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Nursing Care of Children ATI

1. The apnea monitor alarm sounds on a neonate for the third time during this shift. What is the priority action by the nurse?

Correct answer: D

Rationale: The priority action for the nurse when the apnea monitor alarm sounds on a neonate is to assess the infant for color and the presence of respirations. This initial assessment helps determine the infant's respiratory status and the need for immediate intervention. Providing tactile stimulation or administering oxygen should only be done after assessing the infant's respiratory status. Investigating possible causes of a false alarm comes after ensuring the infant's well-being through the initial assessment.

2. A mother tells the nurse that she does not want her infant immunized because of the discomfort associated with injections. What should the nurse explain?

Correct answer: D

Rationale: The nurse should explain that a topical anesthetic can be applied to the injection site before the immunization to reduce discomfort.

3. The parents of a 12-month-old child ask the nurse if the child can eat hot dogs as do their other children. The nurse’s reply should be based on what?

Correct answer: D

Rationale: Cutting hot dogs into small, irregular pieces reduces the risk of aspiration, which is a significant choking hazard for young children.

4. Following treatment for iron deficiency anemia, the physician orders lab tests. Which lab value would indicate an improvement in the child’s condition?

Correct answer: C

Rationale: A high reticulocyte count indicates that the bone marrow is producing more red blood cells, which is a sign of recovery from anemia as the body replenishes its iron stores and increases hemoglobin levels. Low hemoglobin (Choice A) would indicate ongoing anemia rather than improvement. A normal platelet count (Choice B) and low hematocrit (Choice D) are not specific indicators of improvement in iron deficiency anemia.

5. What pathologic process is believed to be responsible for the development of postinfectious glomerulonephritis?

Correct answer: B

Rationale: Postinfectious glomerulonephritis is typically caused by immune complex deposition in the glomeruli following a streptococcal infection. This immune response leads to inflammation and impaired kidney function.

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