the nurse performs a physical assessment of a newborn it is most important for the nurse to report which of the following findings

ATI RN

ATI RN Custom Exams Set 4

1. During a physical assessment of a newborn, which of the following findings should the nurse prioritize reporting?

A. Head circumference of 40 cm
B. Chest circumference of 32 cm
C. Acrocyanosis and edema of the scalp
D. Heart rate of 160 bpm and respirations of 40/min

Correct answer: A

Rationale: The correct answer is A. A head circumference of 40 cm is abnormally large for a newborn and could indicate conditions like hydrocephalus or other abnormalities, making it a crucial finding to report. Choices B, C, and D are within normal parameters for a newborn and do not pose immediate concerns. Chest circumference of 32 cm is a normal finding. Acrocyanosis and edema of the scalp are common in newborns due to physiological adaptations. A heart rate of 160 bpm and respirations of 40/min may be within the normal range for a newborn.

2. Which situations are classified as natural disasters?

A. Blizzards
B. A, C
C. Volcanic eruptions
D. Structural collapse

Correct answer: B

Rationale: The correct answer is B. Blizzards and volcanic eruptions are both examples of natural disasters caused by natural forces such as extreme weather conditions and tectonic activities. On the other hand, structural collapse is typically a result of man-made factors like poor construction or maintenance. Therefore, choices A, C, and D are incorrect as only blizzards and volcanic eruptions are classified as natural disasters.

3. The client diagnosed with Type 2 diabetes mellitus is being taught about diet by the nurse. Which diet selection indicates the client understands the teaching?

A. A submarine sandwich, potato chips, and diet cola
B. Four (4) slices of a supreme thin-crust pizza and milk
C. Smoked turkey sandwich, celery sticks, and unsweetened tea
D. A roast beef sandwich, fried onion rings, and a cola

Correct answer: C

Rationale: The correct answer is C because a smoked turkey sandwich with celery sticks and unsweetened tea reflects a balanced and healthy choice suitable for a client with Type 2 diabetes mellitus. Turkey is a lean protein choice, celery sticks offer fiber and low calories, and unsweetened tea is a sugar-free beverage. Choices A, B, and D are incorrect as they include high-carb, high-fat, and sugary options that are not recommended for individuals with diabetes as they can spike blood sugar levels.

4. The nurse is preparing the plan of care for a client with fluid volume deficit. Which interventions should the nurse include in the plan of care?

A. Monitor vital signs every two (2) hours until stable
B. Weigh the client in the same clothing at the same time daily
C. Administer mouth care every eight (8) hours
D. A, B, and C

Correct answer: D

Rationale: The correct interventions to include in the plan of care for a client with fluid volume deficit are monitoring vital signs every two hours until stable, weighing the client in the same clothing at the same time daily, and assessing skin turgor. These interventions are crucial for managing and detecting fluid volume changes. Administering mouth care every eight hours is not directly related to managing fluid volume deficit and does not address the key aspects of monitoring and assessing fluid status, making it an incorrect choice.

5. Which type of anemia is associated with chronic kidney disease?

A. Iron-deficiency anemia
B. Vitamin B12 deficiency anemia
C. Aplastic anemia
D. Erythropoietin deficiency anemia

Correct answer: D

Rationale: The correct answer is D, Erythropoietin deficiency anemia. Chronic kidney disease often leads to anemia due to decreased production of erythropoietin. This hormone, produced by the kidneys, stimulates the bone marrow to produce red blood cells. Choices A, B, and C are incorrect. Iron-deficiency anemia is characterized by low iron levels, vitamin B12 deficiency anemia by inadequate vitamin B12, and aplastic anemia by bone marrow failure.