ATI RN
Postpartum Hormonal Changes Questions
Question 1 of 5
A full-term newborn was just born. Which nursing intervention is important for the nurse to perform first?
Correct Answer: B
Rationale: In the immediate postpartum period, assessing the Apgar score is crucial as it provides a quick snapshot of the newborn's overall condition and helps determine if any immediate interventions are needed. The Apgar score evaluates the baby's heart rate, respiratory effort, muscle tone, reflex irritability, and color at one minute and five minutes after birth. This quick assessment guides the nurse in determining the need for resuscitative measures or additional monitoring. Removing wet blankets (option A) is important for maintaining the newborn's body temperature but is not as time-sensitive as assessing the Apgar score. Inserting eye prophylaxis (option C) and eliciting the Moro reflex (option D) are important assessments but are not the priority immediately after birth. In an educational context, understanding the significance of the Apgar score and its role in the initial assessment of newborns is essential for nurses and other healthcare providers working in labor and delivery or postpartum units. This knowledge ensures that appropriate care is provided promptly, promoting the well-being of the newborn and facilitating early interventions if necessary.
Question 2 of 5
A 2-day-old breastfeeding baby born via normal spontaneous vaginal delivery has just been weighed in the newborn nursery. The nurse determines that the baby has lost 3.5% of the birth weight. Which of the following nursing actions is appropriate?
Correct Answer: A
Rationale: In the postpartum period, it is normal for newborns to experience some weight loss before they begin to gain weight steadily. A weight loss of up to 7-10% is considered normal for breastfed infants. This weight loss is mainly due to the loss of excess fluid and meconium in the baby's system. In this scenario, the appropriate nursing action is to do nothing because a weight loss of 3.5% is within the normal range for a breastfed newborn. It is crucial to educate parents about expected newborn weight fluctuations to prevent unnecessary anxiety. It is also important to support and encourage breastfeeding, as it has numerous benefits for both the baby and the mother. Option B is incorrect because notifying the neonatologist of a normal weight loss can cause unnecessary alarm and intervention. Option C is incorrect as there is no need to switch to bottle feeding based on a normal weight loss percentage. Option D is also incorrect because assessing for hypoglycemia is not indicated in this scenario where the weight loss is within normal limits. Educationally, it is essential for healthcare professionals to be knowledgeable about normal newborn weight fluctuations, as this knowledge guides appropriate care and counseling for parents. Understanding the physiology of newborns helps in providing evidence-based care and support for families during the postpartum period. By explaining these concepts to parents, nurses can alleviate concerns and promote a positive breastfeeding experience.
Question 3 of 5
The pediatrician has ordered vitamin K 0.5 mg IM for a newborn. The medication is available as 2 mg/mL. How many milliliters (mL) should the nurse administer to the baby? Calculate to the nearest hundredth.
Correct Answer: A
Rationale: In this scenario, the correct answer is option A) 0.25 mL. To administer the prescribed dose of 0.5 mg of vitamin K to the newborn, the nurse needs to calculate the volume of the medication to be given. Since the medication is available as 2 mg/mL, the nurse can use the formula: Volume (mL) = Dose (mg) / Concentration (mg/mL) Volume (mL) = 0.5 mg / 2 mg/mL Volume (mL) = 0.25 mL Therefore, the nurse should administer 0.25 mL of the medication to the newborn. Option B) 0.50 mL is incorrect because it represents the total dose prescribed rather than the calculated volume based on the concentration of the medication. Option C) 1.00 mL is incorrect as it does not accurately reflect the calculated volume needed for the prescribed dose. Option D) 2.00 mL is incorrect as it represents the total volume of the medication available, not the required dose for the newborn. Understanding medication calculations is crucial for nurses to ensure accurate administration of medications, especially in neonatal care where dosages need to be precise to prevent adverse effects. This educational context highlights the importance of dosage calculations in pediatric nursing and emphasizes the significance of accuracy in medication administration to ensure patient safety.
Question 4 of 5
A nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of the following actions by the nurse is appropriate?
Correct Answer: C
Rationale: In this scenario, the appropriate action for the nurse to take is to swaddle the baby in a blanket (Option C). Explanation of correct answer: Swaddling the baby in a blanket helps to provide warmth and comfort, which can help improve circulation and alleviate the cyanosis in the hands and feet of the newborn. Newborns often have difficulty regulating their body temperature, and swaddling can help maintain their warmth and keep them calm. Explanation of why others are wrong: A) Placing the child in an isolette (Option A) may not address the immediate need to provide warmth and comfort to the baby. B) Administering oxygen (Option B) may not be necessary as the cyanosis in this case is likely due to peripheral vasoconstriction rather than a lack of oxygen. D) Applying a pulse oximeter (Option D) may provide information about oxygen saturation but does not address the underlying cause of cyanosis in the extremities. Educational context: Understanding the normal physiological changes that occur in newborns is crucial for healthcare providers working with neonates. In the first hours after birth, infants may exhibit cyanosis in their hands and feet due to peripheral vasoconstriction, which is a normal response to the transition from intrauterine to extrauterine life. Providing warmth and comfort through swaddling can help alleviate this transient condition and support the newborn's adjustment to the outside environment.
Question 5 of 5
A baby boy is to be circumcised by the mother's obstetrician. Which of the following actions shows that the nurse is being a patient advocate?
Correct Answer: B
Rationale: In this scenario, option B is the correct answer. The nurse preparing the sterile field for the physician demonstrates patient advocacy by ensuring that the procedure is conducted in a safe and hygienic manner, prioritizing the well-being of the baby. Option A is incorrect because simply acting before the procedure does not necessarily indicate advocacy. Option C is wrong because refusing to unclothe the baby until pain medication is ordered does not address the immediate needs of preparing for the circumcision. Option D is also incorrect as holding a feeding immediately before the circumcision is not directly related to advocating for the patient's safety during the procedure. Educationally, this question highlights the importance of advocating for patients by ensuring their safety and well-being during medical procedures. It emphasizes the role of nurses in safeguarding their patients' interests and promoting optimal outcomes through proactive and attentive care.