ATI RN
Nursing Care of the Newborn and Family Questions
Question 1 of 5
A mother conveys concern over the fact that she is not certain if her newborn is receiving enough nutrients from breastfeeding. This is the baby's first clinic visit after birth. What information can you provide that will help alleviate her fears regarding nutrient status for her newborn?
Correct Answer: A
Rationale: Step 1: Monitoring the infant's output through diaper changes is a reliable indicator of sufficient nutrient intake. Step 2: Six or more diapers changed in a 24-hour period signifies that the baby is getting enough nutrients from breastfeeding. Step 3: This method is practical and easy for the mother to observe and track regularly. Step 4: It reassures the mother that her newborn is receiving adequate nutrition, addressing her concerns effectively. Summary: - Choice A is correct as it provides a tangible and practical method for assessing the baby's nutrient intake. - Choice B is incorrect as satisfaction with feeding does not directly correlate with nutrient intake. - Choice C is incorrect as it oversimplifies the situation and does not offer a practical solution. - Choice D is incorrect as providing pamphlets may not address the mother's immediate concerns about the baby's nutrient status.
Question 2 of 5
What kind of muscle tone does a preterm newborn have compared to a full-term newborn?
Correct Answer: D
Rationale: The correct answer is D: flaccid. Preterm newborns typically have lower muscle tone compared to full-term newborns due to their immature nervous system. This results in a lack of firmness or strength in their muscles, leading to a flaccid appearance. Choice A is incorrect because preterm newborns do not have firm muscle tone. Choice B is incorrect as it is too general and does not specify the type of abnormality. Choice C is incorrect because preterm newborns do not have normal muscle tone like full-term newborns.
Question 3 of 5
Of the three fetal shunts, which one moves fetal blood from the lungs through the right atrium to the left atrium?
Correct Answer: B
Rationale: The correct answer is B: foramen ovale. The foramen ovale is a shunt that allows blood to bypass the fetal lungs by connecting the right atrium to the left atrium. This is important in utero to ensure oxygenated blood goes directly to the body. The other options are incorrect because: A: Ductus venosus - connects the umbilical vein to the inferior vena cava, bypassing the liver. C: Ductus arteriosus - connects the pulmonary artery to the aorta, bypassing the fetal lungs. D: Foramen venosus - does not exist; it is not a fetal shunt.
Question 4 of 5
A newborn at 20 minutes of age has an axillary temperature of 36° C (96.8° F). What intervention should the nurse perform?
Correct Answer: A
Rationale: The correct answer is A: ensure skin-to-skin contact until temperature is 37°C (98.6°F). Skin-to-skin contact helps regulate the baby's temperature by utilizing the parent's body heat. This method is gentle and effective in stabilizing the baby's temperature without the risk of overheating or cooling too quickly. It promotes bonding and breastfeeding initiation. Choice B is incorrect because giving the baby a warm bath may lead to overheating and should not be done for a newborn with a slightly low temperature. Choice C is incorrect because using a radiant warmer may be too aggressive for a mild temperature drop. Choice D is incorrect because rectal temperature checking is invasive and unnecessary at this point.
Question 5 of 5
The nurse is caring for a neonate born at 36 weeks, 2 days by primary cesarean birth and weighing 6 pounds, 4 ounces. The infant cried at delivery, had flexion in all extremities, had a heart rate of 135, had acrocyanosis in hands and feet, and was pale. The infant was placed skin-to-skin with the birthing person and has been latching and cuddling for the past 15 minutes. At 45 minutes, the neonate is found grunting and cool to the touch. What are the nurse's next steps?
Correct Answer: C
Rationale: The correct answer is C: Take the neonate to the radiant warmer and check their temperature. This is the appropriate next step because the neonate is showing signs of potential respiratory distress (grunting) and coolness to the touch, which could indicate hypothermia. Placing the neonate in the radiant warmer will help maintain a stable temperature and facilitate further assessment and intervention. Choice A is incorrect because stimulating the neonate to take deep breaths may not address the underlying issue of potential respiratory distress. Choice B is incorrect because simply wrapping the baby in blankets and cuddling them closer may not address the potential respiratory distress or hypothermia that the neonate is exhibiting. Choice D is incorrect because calling the NICU staff and activating the staff assist light should be done after assessing the neonate's immediate needs, such as addressing potential respiratory distress and hypothermia.