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

ATI RN

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. Which vaccine is contraindicated in a child with a history of severe egg allergy?

Correct answer: C

Rationale: The correct answer is C: Influenza. The influenza vaccine is produced using egg-based technology, so individuals with a severe egg allergy are at risk of an allergic reaction if vaccinated with the influenza vaccine. This is due to the potential presence of egg proteins in the vaccine. Choices A, B, and D are not contraindicated in children with severe egg allergy. The MMR and Varicella vaccines do not pose a risk for children with egg allergies, and the Hepatitis B vaccine is also safe for these individuals.

3. Which is the most frequently used test for measuring visual acuity?

Correct answer: A

Rationale: The Snellen letter chart is the most commonly used test for measuring visual acuity, particularly in school-age children and adults.

4. Which characteristic best describes the fine motor skills of an infant at age 5 months?

Correct answer: D

Rationale: By 5 months, infants develop the ability to grasp objects voluntarily, showing improved motor control. The neat pincer grasp and building towers are skills that develop later.

5. During a well-child checkup, the parent of a 5-year-old child reports the child seems much smaller than the 2 older siblings did at this same age. A review of the medical record reveals that the child is 44 inches tall and weighs 42 pounds. What information should be included in the response by the nurse?

Correct answer: D

Rationale: The correct answer is D. The child is slightly taller than average, but the weight is within normal limits. This information should be reassuring to the parent and provides insights into normal growth patterns. Choice A is incorrect as it inaccurately states that the child is taller than other children this age. Choice B is incorrect because the child's weight is actually within normal limits. Choice C is incorrect as it inaccurately states that the child is shorter in stature than other children this age.

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