ATI RN
Nursing Care of the Newborn and Family Questions
Question 1 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: The correct answer is B: foramen ovale. The foramen ovale is a shunt that allows blood to bypass the fetal lungs by connecting the right atrium to the left atrium. This is important in utero to ensure oxygenated blood goes directly to the body. The other options are incorrect because: A: Ductus venosus - connects the umbilical vein to the inferior vena cava, bypassing the liver. C: Ductus arteriosus - connects the pulmonary artery to the aorta, bypassing the fetal lungs. D: Foramen venosus - does not exist; it is not a fetal shunt.
Question 2 of 5
The nurse is caring for a neonate born at 36 weeks, 2 days by primary cesarean birth and weighing 6 pounds, 4 ounces. The infant cried at delivery, had flexion in all extremities, had a heart rate of 135, had acrocyanosis in hands and feet, and was pale. The infant was placed skin-to-skin with the birthing person and has been latching and cuddling for the past 15 minutes. At 45 minutes, the neonate is found grunting and cool to the touch. What are the nurse's next steps?
Correct Answer: C
Rationale: The correct answer is C: Take the neonate to the radiant warmer and check their temperature. This is the appropriate next step because the neonate is showing signs of potential respiratory distress (grunting) and coolness to the touch, which could indicate hypothermia. Placing the neonate in the radiant warmer will help maintain a stable temperature and facilitate further assessment and intervention. Choice A is incorrect because stimulating the neonate to take deep breaths may not address the underlying issue of potential respiratory distress. Choice B is incorrect because simply wrapping the baby in blankets and cuddling them closer may not address the potential respiratory distress or hypothermia that the neonate is exhibiting. Choice D is incorrect because calling the NICU staff and activating the staff assist light should be done after assessing the neonate's immediate needs, such as addressing potential respiratory distress and hypothermia.
Question 3 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 4 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 5 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.