A nurse is collecting data on a newborn who is 3 days old.
Exhibit 1
History and Physical
Newborn was delivered at 37 weeks gestation via cesarean section for fetal distress.Apgar scores 8 at 1 min and 9 at 5 min.Birthweight 2,892 g (6 lb 6 oz)The client who gave birth plans to breastfeed.
Exhi...
ATI PN Comprehensive Online Practice Exam 5
2024
A nurse is collecting data on a newborn who is 3 days old.
Exhibit 1
History and Physical
Newborn was delivered at 37 weeks gestation via cesarean section for fetal distress.Apgar scores
8 at 1 min and 9 at 5 min.Birthweight 2,892 g (6 lb 6 oz)The client who gave birth plans to
breastfeed.
Exhibit 2
Flow Sheet
Day 2 of Life
0900:
Temperature 36.7° C (98° F)Heart rate 140/minRespiratory rate 48/minWeight 2,718 g (6 lb),
6% weight lossDay 3 of Life
0800:
Temperature 36.4° C (97.5° F)Heart rate 140/minRespiratory rate 48/minWeight 2,545 g (5 lb 9
oz), 12% weight loss
Exhibit 3
Nurses' Notes
Day 3 of Life
0800:
Skin color consistent with newborn's genetic background. Respirations easy and unlabored.
Abdomen soft with active bowel sounds. Mild tremors noted when awake. Anterior fontanel
level and soft. Large ecchymotic caput succedaneum noted on posterior scalp. Small amount of
bloody mucus discharge noted from vag - Click to highlight the findings that require follow-up.
To deselect a finding, click on the finding again.
Temperature 36.4° C (97.5° F)
Weight 2,545 g (5 lb 9 oz) 12% weight loss
Mild tremors noted when awake.
Breastfeeding every 3 to 5 hr for 5 to 10 min.
Birth parent reports nipple discomfort throughout the feeding.
When recognizing cues, the nurse should identify that a temperature of 36.4° C (97.5° F) is
below the expected reference range. Hypothermia can lead to the occurrence of hypoglycemia
and respiratory distress. The newborn breastfeeding for short intervals, nipple discomfort, and a
weight loss of greater than 10% of birth weight can indicate inadequate transfer of breastmilk,
which can result in hypoglycemia. The presence of mild tremors can be a manifestation of
hypoglycemia.
, A nurse is assisting with the care of a client who was admitted to the emergency department
(ED).
Exhibit 1
Admission Assessment
Day 1
1930:
Client admitted to the ED by police after report of violent behavior in public. Client smashed a
glass window with their hands. Client is stating, "I am Jesus." Client is attempting to hit staff.
Client placed in restraints. Neuro: Client is alert and oriented x 0. Client is swinging their arms
and shouting. Client is unable to answer questions and their speech is rapid and unorganized.
Heart rate is 108/min, regularIntegumentary: Laceration noted to the client's left hand (2 cm x
2.5 cm). Laceration noted to the left forearm (4 cm x 6 cm). Profuse bleeding noted. Multiple
small lacerations noted to face, left arm, and right arm. Allergies: Unable to assess
Exhibit 2
Vital Signs
Day 1
1930:
Temperature 36.7° C (98.0° F)Pulse 108/minRespiratory rate 24/minBP 150/92 mm Hg1945:
P - For each potential assessment finding, click to specify if the finding is consistent with
schizophrenia or bipolar 1 disorder. Each finding may support more than 1 disease process.
When analyzing cues, the nurse should distinguish between positive and negative manifestations
of schizophrenia and bipolar 1 disorder. The client is displaying positive manifestations of
schizophrenia, when compared to the assessment findings of a client who has bipolar 1 disorder.
A nurse is caring for a client in an inpatient mental health facility.
Exhibit 1
Medical HistoryClient is 44 years old, well-nourished, presenting with recurrence of labile
behavior involving self-mutilation, recent arrest for reckless driving, stealing money from work
for gambling debts, depressive episodes, and binge eating.Provider's skin assessment reveals
multiple superficial self-inflicted lacerations to right arm.
Client plays golf three mornings per week.
Employed as salesperson at a car dealership for 8 years.
Exhibit 2
Nurses' Notes
Day 1
1500:
Client is talkative, well-groomed.
Expresses anxiety when left alone and states they would prefer a roommate. The client tends to
be the center of attention in the dayroom.
1600:
Client assigned a roommate.Day 2
1300:
Pacing for last hour and mumbling to self. Argued with staff earlier about going to lunch in the
cafeteria.
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