A client has postpartum psychosis. Which of the following actions is the nurse's priority?

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ATI Maternal Newborn Questions

Question 1 of 5

A client has postpartum psychosis. Which of the following actions is the nurse's priority?

Correct Answer: B

Rationale: The correct answer is B: Ask the client if they have thoughts of harming themselves or their infant. This is the priority because postpartum psychosis poses a risk of harm to the client and the infant. Assessing for suicidal or homicidal ideation is crucial to ensure safety. Choice A may be important but ensuring immediate safety takes precedence. Choice C is important but not the priority. Choice D may provide background information but does not address the immediate safety concern.

Question 2 of 5

During an assessment, a healthcare provider observes small pearly white nodules on the roof of a newborn's mouth. This finding is a characteristic of which of the following conditions?

Correct Answer: D

Rationale: The correct answer is D: Epstein's pearls. These small pearly white nodules are commonly found on the roof of newborns' mouths and are considered a normal finding. They are formed from trapped epithelial cells during the development of the baby's mouth. They are harmless and typically resolve on their own without treatment. A: Mongolian spots are bluish-black or bruise-like markings found on the skin, not in the mouth. B: Milia spots are small, white, raised bumps on the skin, not found in the mouth. C: Erythema toxicum is a common benign rash in newborns, not related to the mouth. In summary, Epstein's pearls are the correct answer due to their specific location in the newborn's mouth, their appearance, and the fact that they are a normal finding in newborns. The other choices are incorrect as they describe different conditions not related to the oral cavity.

Question 3 of 5

When checking for the Moro reflex in a newborn, what action should the nurse take?

Correct Answer: D

Rationale: The correct answer is D because the Moro reflex is elicited by sudden head movement or loud noise, causing the infant to extend their arms, then bring them back in a hugging motion. By holding the newborn in a semi-sitting position and allowing their head and trunk to fall backward, the nurse can observe the Moro reflex. Choices A, B, and C do not correctly elicit the Moro reflex as they involve different stimuli or movements that do not trigger the characteristic response of arm extension followed by flexion.

Question 4 of 5

When reinforcing teaching with new parents on bathing a newborn, a nurse observes a bluish-brown marking across the newborn's lower back. Which of the following statements should the nurse make concerning the variation?

Correct Answer: A

Rationale: The correct answer is A: This is more commonly seen in newborns who have dark skin. The bluish-brown marking described is likely a Mongolian spot, a common birthmark in darker-skinned infants. It is not related to hyperbilirubinemia (jaundice), forceps marks, or birth trauma. Mongolian spots are benign and typically fade over time. This statement is correct as it addresses the specific characteristic of the marking and its association with dark skin pigmentation in newborns.

Question 5 of 5

A healthcare professional is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. Which of the following medications should the healthcare professional anticipate administering?

Correct Answer: C

Rationale: The correct answer is C: Erythromycin. Erythromycin is the standard treatment for preventing ophthalmia neonatorum, a condition caused by Neisseria gonorrhoeae or Chlamydia trachomatis. It is a broad-spectrum antibiotic that effectively prevents bacterial infections in newborns. Ofloxacin (A) is a fluoroquinolone antibiotic not typically used in newborns. Nystatin (B) is an antifungal medication used for treating fungal infections, not bacterial infections like ophthalmia neonatorum. Ceftriaxone (D) is a cephalosporin antibiotic used for various bacterial infections, but it is not the first-line treatment for preventing ophthalmia neonatorum.

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