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. In general, how much is a child that was 10 pounds at birth expected to weigh at 6 months old?

Correct answer: A

Rationale: The correct answer is A. A child is expected to double their birth weight by 6 months. This is a common guideline used to monitor healthy growth and development in infants. Choices B, C, and D are incorrect as they do not provide the expected weight based on the given information.

3. The nurse is assessing a child with type 2 diabetes. The child is awake and alert with a serum glucose of 60 mg/dL. What action should the nurse take?

Correct answer: C

Rationale: For a conscious child with mild hypoglycemia, giving 15 grams of fast-acting carbohydrates is the appropriate intervention. This can quickly raise blood glucose levels to prevent further complications. Administering insulin (Choice A) would further lower the glucose level, which is not suitable in this scenario. Administering epinephrine (Choice B) is not indicated for hypoglycemia. Glucagon (Choice D) is used for severe hypoglycemia with altered consciousness, not for mild cases where the child is awake and alert.

4. The school nurse is evaluating the number of school-age children classified as obese. The nurse recognizes that the percentile of body mass index that classifies a child as obese is greater than which?

Correct answer: D

Rationale: A child with a BMI greater than the 95th percentile is classified as obese, according to standard growth charts used in pediatric practice.

5. What is the most frequent cause of hypovolemic shock in children?

Correct answer: B

Rationale: Hypovolemic shock in children is most frequently caused by blood loss, which can result from trauma, surgery, or gastrointestinal bleeding. Sepsis and anaphylaxis can lead to different types of shock (septic and anaphylactic), and heart failure is related to cardiogenic shock.

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