A nurse is caring for a client who is 1 day postpartum and is taking a sitz bath. To determine the client's tolerance of the procedure, which of the following assessments should the nurse perform?

Correct Answer: B

Rationale: The nurse should assess the client's pulse rate to determine the client's tolerance of the sitz bath. An elevated pulse may indicate that the sitz bath is causing discomfort or stress to the client. Monitoring the pulse rate is essential to ensure the client's safety and comfort during the procedure. Bladder distention, respiratory rate, and color of lochia are important assessments in postpartum care but are not specifically related to determining the client's tolerance of a sitz bath.

Correct Answer: D

Rationale: In newborns, respiratory distress can present with various signs and symptoms. The combination of tachypnea (rapid breathing), chest retractions (visible sinking of the skin in between or below the ribs with each breath), grunting (sound made during expiration), and cyanosis (blue discoloration of the skin and mucous membranes) are indicative of respiratory distress in a newborn. These signs suggest that the newborn is having difficulty breathing and may require immediate medical attention. It is essential to recognize and address respiratory distress promptly to ensure the well-being of the newborn.

Correct Answer: B

Rationale: In the context of pharmacology and neonatal care, the most appropriate action for a nurse when a newborn has jaundice on the second day of life is to initiate phototherapy (Option B). Jaundice in newborns occurs due to the accumulation of bilirubin, a yellow pigment produced during the breakdown of red blood cells. Phototherapy involves exposing the baby's skin to a special type of light that helps convert the bilirubin into a form that can be easily excreted by the body. Increasing fluid intake of the mother (Option A) is not the primary intervention for newborn jaundice. While adequate hydration is important for both the mother and baby, it will not directly address the elevated bilirubin levels in the newborn. Monitoring bilirubin levels (Option C) is essential in the management of jaundice, but in the case of significant jaundice on the second day of life, immediate intervention with phototherapy is crucial to prevent complications such as kernicterus. Referring to a pediatric specialist (Option D) may be necessary in complex cases or if the jaundice does not improve with phototherapy. However, the initial and urgent step in managing neonatal jaundice is phototherapy to prevent the potential neurotoxic effects of high bilirubin levels. In an educational context, understanding the pathophysiology of neonatal jaundice and the appropriate interventions is vital for nurses caring for newborns. Prompt recognition and management of jaundice can prevent serious complications and ensure optimal outcomes for the newborn.

Correct Answer: B

Rationale: The correct answer is B) Rooting reflex. When a newborn's cheek is stroked, they will turn their head towards that side and open their mouth in search of a nipple for feeding. This reflex is essential for successful breastfeeding initiation as it helps the newborn locate the source of food. Option A, Startle reflex, is elicited by a sudden loud noise or a bright light, causing the newborn to spread out their arms and legs then bring them back in. This reflex is not assessed by stroking the cheek. Option C, Babinski reflex, is assessed by stroking the sole of the foot, resulting in the toes fanning out. This reflex is not related to stroking the cheek. Option D, Sucking reflex, is elicited by touching the roof of the newborn's mouth, causing them to start sucking. While important for feeding, this reflex is not assessed by stroking the cheek. Understanding newborn reflexes is crucial for healthcare providers working with infants to assess their neurodevelopmental status and ensure their well-being. By correctly identifying and interpreting these reflexes, healthcare professionals can intervene early if any abnormalities are noted, promoting optimal growth and development in newborns.

Correct Answer: B

Rationale: In the context of pharmacology within the maternal newborn setting, educating a mother about kangaroo care for her preterm infant is crucial. The correct answer is B) Educate about skin-to-skin contact benefits. Kangaroo care involves placing the baby skin-to-skin on the mother's chest, providing numerous benefits such as regulating the baby's temperature, heart rate, and promoting bonding and breastfeeding. Option A) Encouraging frequent visits to the NICU may be important for overall involvement, but it does not specifically address the benefits of kangaroo care. Option C) Explaining the importance of bonding is relevant, but it does not provide specific guidance on how to implement kangaroo care. Option D) Teaching the mother about safe handling of the newborn is important, but it does not directly address the benefits of skin-to-skin contact through kangaroo care. In the ATI Maternal Newborn Proctored Exam, understanding the benefits of kangaroo care and how to educate mothers on this practice is essential for providing optimal care to preterm infants. By choosing the correct answer, nurses can empower mothers with the knowledge and skills needed to enhance the well-being of their newborns through skin-to-skin contact.