ATI RN
Nursing Care of the Newborn and Family Questions
Question 1 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 2 of 5
A new parent asks the nurse why the 36-hour-old newborn has a yellow skin tint. What should the nurse explain to the parent?
Correct Answer: D
Rationale: The correct answer is D because physiologic jaundice is a normal condition in newborns due to the breakdown of fetal red blood cells. Bilirubin, a byproduct of this breakdown, causes the yellow skin tint. The liver is still developing in newborns, so it may take some time for it to process and eliminate the excess bilirubin. Choice A is incorrect because it implies liver dysfunction, which is not the case in physiologic jaundice. Choice B is incorrect as yellow skin does not indicate brain damage. Choice C is incorrect because bilirubin is primarily excreted through the liver, not the bowels, in newborns.
Question 3 of 5
A new parent is concerned about a mass on the newborn's head. The nurse assesses this to be a cephalohematoma based on what characteristics?
Correct Answer: B
Rationale: The correct answer is B because a cephalohematoma is a collection of blood between the skull bone and its periosteum. It is usually unilateral and does not cross suture lines. Choice A is incorrect because cephalohematomas do not appear suddenly. Choice C is incorrect as cephalohematomas do not cause the head to feel boggy or cross suture lines. Choice D is incorrect because the mass does not increase in size when the infant cries.
Question 4 of 5
How would the nurse elicit a rooting reflex in a newborn?
Correct Answer: A
Rationale: The correct answer is A because eliciting the rooting reflex in a newborn involves gently rubbing a finger on the side of the cheek. This reflex is important for feeding as it helps the baby turn their head towards the stimulus to locate the nipple for feeding. This action triggers a sucking response. The other choices are incorrect as they do not specifically target the rooting reflex. Choice B refers to the palmar grasp reflex, choice C is related to the sucking reflex, and choice D describes the Moro reflex. These reflexes are different from the rooting reflex and have distinct elicitation methods.
Question 5 of 5
The nurse knows that a full-term newborn presents with ears that include what assessment characteristics?
Correct Answer: B
Rationale: The correct answer is B because a full-term newborn typically has well-curved pinna that is soft and has a ready recoil. This indicates normal ear development and flexibility in newborns. Choice A is incorrect as a slightly curved pinna with slow recoil is not characteristic of a full-term newborn. Choices C and D are incorrect as thick cartilage with a stiff ear or a flat pinna that stays folded are not typical findings in full-term newborns. Therefore, the characteristics described in choice B align with normal ear development in a full-term newborn.