ATI RN
Nursing Care of the Newborn Questions
Question 1 of 5
A neonate has difficulty maintaining a normal temperature. A student nurse prepares to place the infant under a radiant warmer. What action by the student leads the faculty member to intervene?
Correct Answer: D
Rationale: In this scenario, the correct answer is option D - "Wraps the baby in a warmed blanket." Placing the baby under a radiant warmer is a common intervention to help maintain the neonate's body temperature. By wrapping the baby in a warmed blanket, the student nurse is assisting in preventing heat loss and promoting thermoregulation, which is crucial for newborns who have difficulty maintaining their body temperature. Option A, assessing the surrounding area for drafts, is not the most immediate or direct action needed to address the neonate's temperature instability. While it is important to ensure a draft-free environment for a newborn, in this case, the priority is to provide direct warmth to the infant. Option B, ensuring the infant is dried off completely, is also important for preventing heat loss. However, the most immediate intervention to address the neonate's temperature regulation issue is to provide direct warmth through a warmed blanket or radiant warmer. Option C, observing the respiratory rate at the same time, is not directly related to the immediate need of addressing the neonate's temperature instability. While monitoring the respiratory rate is essential in newborn care, in this scenario, the primary focus should be on providing warmth to the infant. In educational context, understanding the importance of thermoregulation in newborns and knowing the appropriate interventions to help maintain their body temperature is crucial for nursing students caring for neonates. This scenario highlights the need for prioritizing interventions based on the immediate needs of the patient.
Question 2 of 5
A faculty member explains to a nursing student that the best way to prevent hemorrhage from injuries in a neonate is which of the following?
Correct Answer: A
Rationale: In the context of pharmacology and nursing care of the newborn, administering vitamin K1 phytonadione (AquaMEPHYTON) is the best way to prevent hemorrhage from injuries in a neonate. This is because vitamin K is essential for the synthesis of clotting factors in the liver, and newborns have lower levels of vitamin K at birth, putting them at risk for bleeding disorders. Option A is correct as it directly addresses the deficiency in newborns and helps prevent hemorrhage. Handling the infant carefully while wearing soft gloves (Option B) is important for infection control but does not directly prevent hemorrhage. Keeping the infant swaddled in several layers of blankets (Option C) and teaching parents how to trim the baby's fingernails (Option D) do not address the underlying physiological issue of vitamin K deficiency leading to hemorrhage. Educationally, understanding the importance of vitamin K administration in newborn care is crucial for nursing students to provide safe and effective care to neonates. It highlights the significance of recognizing and addressing potential bleeding risks in this vulnerable population. This rationale emphasizes the pharmacological aspect of nursing care and underscores the importance of evidence-based practices in neonatal healthcare.
Question 3 of 5
A term infants initial blood glucose level is 42 mg/dL. What action by the nurse is most appropriate?
Correct Answer: A
Rationale: The most appropriate action by the nurse in this scenario is to document the finding of the infant's initial blood glucose level of 42 mg/dL in the infant's chart (Option A). This is because the blood glucose level of 42 mg/dL in a term infant is within the normal range for newborns. Term infants typically have lower blood glucose levels in the first few hours after birth due to the transition from intrauterine to extrauterine life. It is crucial for the nurse to document this finding accurately for the infant's medical records and ongoing monitoring. Encouraging the mother to initiate breastfeeding (Option B) is a good practice for promoting bonding and providing essential nutrients to the newborn. However, in this case, immediate breastfeeding may not be necessary as the blood glucose level is within the normal range. Preparing to administer intravenous glucose (Option C) is unnecessary and invasive for a term infant with a blood glucose level of 42 mg/dL. Intravenous glucose administration is usually reserved for newborns with hypoglycemia below the normal range or those who are symptomatic. Rechecking the blood glucose in 2 hours (Option D) is not warranted in this situation since the initial blood glucose level is normal for a term infant. Repeated blood glucose monitoring may cause unnecessary stress to the infant and is not indicated unless the initial levels are abnormal. In an educational context, understanding the normal variations in blood glucose levels in newborns is essential for nurses caring for neonates. It is crucial to differentiate between normal physiological variations and abnormal values to provide appropriate care and interventions. Documenting findings accurately, as in this case, ensures proper communication among healthcare providers and supports the continuity of care for the newborn.
Question 4 of 5
A nurse is beginning a newborns physical assessment and notes that the infant is jumpy and seems irritable when being handled and when the nurse or parents speak. What action by the nurse is best?
Correct Answer: D
Rationale: The correct action for the nurse in this scenario is option D: Postpone the assessment until the infant has calmed. It is crucial to prioritize the infant's well-being and comfort during assessments to ensure accurate results and to promote trust and bonding between the newborn, caregivers, and healthcare providers. Infants can easily become overstimulated, leading to increased irritability and jumpy behavior. By postponing the assessment until the infant has calmed down, the nurse can create a more conducive environment for a thorough and accurate evaluation. Option A: Asking the mother to attempt to breastfeed the infant may not address the underlying issue of the infant's irritability and jumpy behavior. It is important to first allow the infant to calm down before attempting to breastfeed. Option B: Conducting the assessment quickly and then swaddling the baby may further agitate the infant, as the hurried assessment process may not provide accurate results and could lead to increased distress. Option C: Increasing the heat in the room to prevent chilling is not directly related to the infant's behavior and may not address the root cause of the irritability and jumpiness. Educationally, this scenario highlights the importance of considering the newborn's cues and behaviors during assessments, as well as the significance of creating a calm and soothing environment to promote optimal care and outcomes for newborns and their families. It emphasizes the need for healthcare providers to be sensitive to the unique needs of infants and to prioritize their comfort and well-being in all care interactions.
Question 5 of 5
A nurse is assessing an infant who has a large bruise around his neck and face from a nuchal cord. What other assessment finding correlates with this condition?
Correct Answer: A
Rationale: Infants born with a nuchal cord often demonstrate significant bruising to the face and neck. This may be upsetting to the parents. Irritability with handling might be related to damage from birth trauma. Large-for-gestational-age infants often have bruising related to extraction techniques during a difficult birth. Obvious vertebral defects are associated with neural tube anomalies and can be seen in children with hairy pigmented skin lesions and hairy nevi located in the posterior midline area near the spinal column.