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: The correct answer is C) "You will have to arrange screening before the end of the baby's first week of life." This is the correct option because newborn screening for metabolic disorders is typically done within the first few days of life to ensure early detection and intervention if any disorder is present. Screening within the first week allows healthcare providers to promptly identify and manage any metabolic disorders that could potentially be life-threatening if not treated early. Option A) "A blood test will be performed within the first 2 weeks of your baby's life" is incorrect because waiting for 2 weeks could delay necessary interventions for newborns with metabolic disorders. Option B) "Newborns born at home do not need to be screened for metabolic diseases" is incorrect as all newborns, regardless of the birth setting, should undergo screening to detect any potential health issues early on. Option D) "Your birth attendant can draw blood from the umbilical cord for metabolic screening" is incorrect because newborn screening typically involves a blood sample taken from the baby's heel, not from the umbilical cord. In an educational context, it is crucial for healthcare providers to emphasize to pregnant women the importance of timely newborn screening for metabolic disorders to ensure the well-being of the newborn. Educating expectant mothers on the significance of early screening can help prevent serious complications and provide the necessary support and interventions if needed.
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: In the context of scoring an Apgar assessment, the correct answer is D) Grimace is an assessment of the response to stimulation from the nurse. Apgar scores evaluate a newborn's physical condition at 1 and 5 minutes after birth. The "grimace" component assesses the newborn's reflex irritability or response to stimulation, such as gently stroking the newborn's back. This response indicates the normal development of the central nervous system. Option A) is incorrect because the Apgar assessment does not specifically evaluate the newborn's response to taking their first breath. Option B) is incorrect as it describes a different assessment related to the flexion of hips and legs. Option C) is also incorrect as the Apgar assessment focuses on physiological responses rather than emotional or visual stimuli. Understanding the components of the Apgar assessment is crucial for nurses caring for newborns as it helps in quickly evaluating and addressing any potential issues in the newborn's transition to extrauterine life. Nurses must be able to accurately interpret Apgar scores to provide prompt and appropriate interventions for newborns in need of support.