ATI RN
Nursing Care of the Newborn and Family Questions
Question 1 of 5
A new nurse is preparing to administer erythromycin (Eyemycin) to an infant. What action by the new nurse would lead the precepting nurse to intervene?
Correct Answer: B
Rationale: In this scenario, the correct answer is B) Prepares to administer the medication 4 hours after birth. The administration of erythromycin ointment to newborns is typically done within the first hour after birth to prevent neonatal conjunctivitis caused by chlamydia or gonorrhea. Delaying the administration by 4 hours increases the risk of infection transmission to the newborn. Option A is incorrect because applying the medication in a thin strip to each eye is the correct technique for administering erythromycin ointment. Option C is incorrect because starting to administer the medication at the inner canthus is the proper technique to ensure the ointment spreads over the eye. Option D is incorrect because it is important to inform parents that mild irritation can occur as a common side effect of the medication. In an educational context, understanding the correct timing and technique for medication administration in newborns is crucial for nursing care. This knowledge ensures the safety and well-being of the infant, highlighting the importance of adhering to evidence-based practices in pharmacology within the neonatal care setting.
Question 2 of 5
A nurse takes a newborns initial set of vital signs and records the following: Temperature: 97.9F (36.6C) pulse: 198 beats/minute respirations: 78 breaths/minute blood pressure: 64/44 mm Hg. What does the nurse conclude about this infant?
Correct Answer: D
Rationale: In this scenario, the correct answer is D) Tachypneic: suction if needed administer oxygen per protocol. The newborn's vital signs indicate tachypnea (rapid breathing) with a respiratory rate of 78 breaths/minute, which is above the normal range for a newborn. Tachypnea can be a sign of respiratory distress or other underlying issues. The nurse should first assess the baby's airway for any obstructions and suction if necessary. Administering oxygen per protocol is crucial to ensure the baby is receiving adequate oxygenation. Option A) Hypotensive: needs IV fluid administration is incorrect because the blood pressure of 64/44 mm Hg is within the normal range for a newborn. Option B) Hypothermic: needs to be put in an incubator is incorrect because the temperature of 97.9F (36.6C) is slightly lower but still within an acceptable range for a newborn. Option C) Tachycardic: take pulse again when the baby is not crying is incorrect because the pulse rate of 198 beats/minute is likely due to the baby crying and is not a true reflection of the baby's baseline heart rate. In an educational context, understanding newborn vital signs and their implications is crucial for nurses caring for newborns. Recognizing abnormal vital signs and knowing the appropriate interventions are essential skills for providing safe and effective care to newborns in various clinical settings.
Question 3 of 5
A nurse notes that an infant has a drooping tongue which causes difficulty with feeding. What cranial nerve should the nurse assess further?
Correct Answer: A
Rationale: In this scenario, the correct cranial nerve that the nurse should further assess is the Facial nerve (Option A). The Facial nerve (Cranial Nerve VII) is responsible for controlling the muscles of facial expression, including those involved in tongue movement. A drooping tongue can indicate weakness or dysfunction of this nerve, leading to difficulties with feeding. The other options can be ruled out as follows: - Olfactory nerve (Option B) is responsible for the sense of smell and is not related to tongue movement or feeding difficulties. - Trigeminal nerve (Option C) is responsible for sensory innervation of the face and motor functions such as chewing, but it is not directly involved in controlling tongue movement related to feeding. - Vagus nerve (Option D) has a role in parasympathetic control of various organs in the body, but it is not primarily responsible for tongue movement. Educationally, understanding the cranial nerves and their functions is crucial for healthcare professionals, especially nurses working with newborns. Recognizing signs of cranial nerve dysfunction can help in early identification and appropriate management of issues that may impact a newborn's feeding and overall well-being. This knowledge enhances nursing care by ensuring timely interventions and support for infants with feeding difficulties.
Question 4 of 5
A nurse observes a student nurse examining a newborn baby boys scrotum and testicles. The student softly palpates the scrotum with all five digits of the dominant hand and states that there is only one testicle present. What action by the nurse is best?
Correct Answer: C
Rationale: In this scenario, the best action for the nurse to take is option C: Have the student repeat the exam using the proper technique. This is the correct choice because it addresses the immediate concern of ensuring that the newborn baby is properly assessed without jumping to unnecessary actions or causing alarm to the parents. Option A is incorrect because relying solely on familial traits without proper examination and confirmation could lead to overlooking a potential medical issue. Option B is not warranted at this stage as referring to a urologist based solely on a student's initial assessment could be premature and unnecessarily escalate the situation. Educationally, this scenario highlights the importance of proper assessment techniques in nursing care, especially when dealing with newborns. It emphasizes the need for thoroughness, accuracy, and sensitivity in conducting physical examinations. By having the student repeat the exam using the correct technique, the nurse can guide their learning process and ensure that they develop the necessary skills for accurate assessments in the future.
Question 5 of 5
A nurse assessing an infant notes that the baby is jittery, has muscle twitches, and has jittery movement of the arms and legs. What action by the nurse is most appropriate?
Correct Answer: D
Rationale: Hypertonia is characterized by muscle tremors, twitches, or jerkiness, and this finding is often associated with neonatal abstinence syndrome. The nurse should notify the health-care provider and request a drug screen. A warm, quiet environment may be best for this infant, but this action is not the priority. Muscle relaxants and scanning tests are not warranted.