On examination the hands and feet of a 6 hours old infant is cyanotic without signs of distress. The nurse should document these findings as:

Correct Answer: D

Rationale: Acrocyanosis is a condition commonly seen in newborns where the hands and feet appear blue or purple in color due to decreased circulation in the peripheral blood vessels. It is usually a normal finding in newborns and is not associated with distress or poor oxygenation. Unlike central cyanosis which indicates a more serious underlying issue affecting oxygen levels in the blood, acrocyanosis is a benign and self-limiting condition. It is important for the nurse to recognize and document acrocyanosis to differentiate it from other potentially concerning conditions.

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.

Correct Answer: A

Rationale: After a cesarean section, the client should be taught to report symptoms of a urinary tract infection, such as frequency, urgency, and burning on urination. These symptoms can indicate an infection which needs prompt treatment to prevent complications. It is important for the client to report these symptoms to their healthcare provider for appropriate evaluation and management.