ATI RN
Nursing Care of the Newborn and Family Questions
Question 1 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 2 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 3 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.
Question 4 of 5
A full-term newborn has been delivered by a physician after a lengthy labor and delivery. The newborn has poor tone, minimal respiratory effort, and central cyanosis. The cord is cut, and the patient is placed in an infant warmer. What data does the nurse need to notice that are clinically significant? Select all that apply.
Correct Answer: A
Rationale: In this scenario, the correct answer is option A) Assess ABCs in newborn. ABCs stand for Airway, Breathing, and Circulation, which are crucial to assess in a newborn experiencing poor tone, minimal respiratory effort, and central cyanosis. These are vital signs of respiratory distress and require immediate attention to prevent further complications. Option B) Apgar score is determined is not the most immediate concern in this situation. While the Apgar score is important for assessing a newborn's overall condition at specific time points after birth, the priority here is to address the newborn's compromised respiratory status. Option C) Temperature is measured is also important, but not as critical as assessing the newborn's ABCs in a situation where respiratory distress is evident. Temperature regulation is essential for newborns, but it can be addressed once the immediate respiratory needs are met. Option D) Vaccination is ready for administration is irrelevant at this moment as the newborn is in distress and requires urgent respiratory support. Vaccination is a preventive measure that can be administered once the newborn's immediate health needs are addressed. In an educational context, understanding the priorities of newborn assessment in critical situations is essential for nurses caring for newborns. Recognizing signs of respiratory distress and knowing how to respond promptly can make a significant difference in the outcomes for newborns in distress. Prioritizing ABCs ensures that life-saving interventions are initiated promptly, emphasizing the importance of quick and accurate clinical assessments in newborn care.
Question 5 of 5
Of the three fetal shunts, which one moves fetal blood from the lungs through the right atrium to the left atrium?
Correct Answer: B
Rationale: In fetal circulation, the foramen ovale is the fetal shunt that allows blood to bypass the nonfunctional lungs by moving from the right atrium to the left atrium. This shunt is crucial for directing oxygenated blood to the systemic circulation while bypassing the pulmonary circulation, which is unnecessary in the fetal environment. The incorrect options are as follows: A) Ductus venosus: This shunt bypasses the liver, directing partially oxygenated blood from the umbilical vein to the inferior vena cava. C) Ductus arteriosus: This shunt allows blood to bypass the fetal lungs by connecting the pulmonary artery to the aorta. D) Foramen venosus: This is a distractor as it is not a valid anatomical structure. Understanding fetal circulation is essential for healthcare professionals, especially nurses caring for newborns. Knowledge of fetal shunts helps in assessing newborns for potential cardiac issues and in understanding the transition from fetal to neonatal circulation. Recognizing the foramen ovale's function is critical for providing appropriate care to newborns with cardiac anomalies related to these shunts.