ATI RN
Nursing Care of the Newborn and Family Questions
Question 1 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.
Question 2 of 5
New parents wish to include their extended family in welcoming their new baby. What suggestion does the nurse offer this couple?
Correct Answer: D
Rationale: Nurses can foster attachment in several ways, including encouraging parents to invite siblings and other family members to visit for short periods of time to avoid tiring the mother and overstimulating the baby. Of course sick people should not visit. Others can be recruited to feed the baby, and often relatives and close friends desire to do so. If all the visiting takes place when the baby is sleeping, the baby and the visitors cannot get to know each other.
Question 3 of 5
A perinatal clinic nurse is working with a pregnant woman who wishes a home birth. What information about newborn screening for metabolic disorders does the nurse provide?
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 4 of 5
A nurse reads in the chart that a baby has a positive crossed extension reflex and asks a more experienced nurse to demonstrate this assessment. How does the nurse perform the assessment?
Correct Answer: A
Rationale: A positive crossed extension reflex occurs when the infant is supine and one foot is stimulated. The infant should flex, adduct, and then extend the opposite leg. Tapping the forehead is part of the glabellar reflex assessment. The crawling reflex is present when the infant attempts to crawl while prone. The Galant reflex (or trunk incurvation reflex) is assessed with the infant in a prone position. Stroke one side of the vertebral column and watch the baby's buttocks curve toward the side where the stimulation occurred.
Question 5 of 5
When thinking about scoring an Apgar assessment, the nurse knows that grimace is an assessment of what in a newborn?
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.