ATI RN
Maternal and Reproductive Health Nursing Questions
Question 1 of 5
The clinic nurse observes that a 3-day-old baby girl is jaundiced. A bilirubin level is 11.4 mg/dL (194.99 umol/L). What causes this bilirubin level?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) Physiologic jaundice. Physiologic jaundice is a common condition in newborns due to the breakdown of red blood cells and the liver's immaturity in processing bilirubin. Option B) Hemolytic disease of the newborn is incorrect because this condition results from Rh incompatibility between the mother and baby's blood types, leading to excessive breakdown of red blood cells. Option C) Erythroblastosis fetalis, another term for hemolytic disease of the newborn, is also incorrect due to the mismatch in blood types between the mother and baby, causing the baby to produce antibodies against its own red blood cells. Option D) Sepsis is incorrect as it refers to a severe infection in the baby's bloodstream, which can cause jaundice but is not the primary cause in this case. In an educational context, understanding the different causes of neonatal jaundice is crucial for nurses to provide appropriate care and interventions. Physiologic jaundice is a common occurrence that usually resolves without treatment, while other causes may require specific management strategies to prevent complications. Nurses must be able to differentiate between these causes to ensure the well-being of newborns.
Question 2 of 5
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: In this scenario, the correct answer is D) Acrocyanosis. Acrocyanosis is a condition commonly seen in newborns where there is a bluish discoloration of the hands and feet due to peripheral vasoconstriction. It is a normal finding in newborns and typically does not indicate any underlying health issues. Option A) Potential for respiratory distress is incorrect because there are no signs of respiratory distress mentioned in the scenario. Option B) Poor oxygenation is also incorrect as acrocyanosis does not necessarily indicate poor oxygenation. Option C) Cold stress is not the correct answer in this case as acrocyanosis is not solely caused by cold stress. Educationally, it is important for nurses to be familiar with normal variations in newborn assessments to differentiate between what is normal and what may require further investigation or intervention. Understanding acrocyanosis as a benign condition helps nurses provide appropriate care without unnecessary alarm or intervention. This knowledge contributes to accurate documentation and effective communication within the healthcare team.
Question 3 of 5
The parents of a male newborn ask the nurse whether they should have their son circumcised. The nurse ‘s most appropriate response would be:
Correct Answer: D
Rationale: The correct answer is option D: "I'm sure you have discussed this with your doctor, but let's review the benefits and risks of circumcision." This response is the most appropriate because it acknowledges the parents' previous discussions with their doctor while also promoting an informed decision-making process through an open dialogue about the benefits and risks of circumcision. Option A is incorrect because although some studies suggest a reduced risk of penile cancer with circumcision, the evidence is not strong enough to recommend routine circumcision solely for this reason. Option B is not the best choice as it does not provide the parents with valuable information or guidance to make an informed decision. Option C is incorrect because it misrepresents the current stance of the American Academy of Pediatrics, which recognizes that the decision to circumcise is a personal one and should be made by the parents after receiving accurate and unbiased information. In an educational context, it is crucial for nurses to approach discussions about circumcision with sensitivity, respect, and a focus on providing evidence-based information to empower parents to make informed decisions about their child's health. By engaging in open and non-judgmental conversations, nurses can support parents in navigating the complex decision-making process surrounding circumcision, ultimately promoting the well-being of both the newborn and the family.
Question 4 of 5
A male infant delivered at 28 weeks gestation weighs 2 pounds, 12 ounces. When performing an assessment, the nurse would probably observe:
Correct Answer: B
Rationale: In this scenario, the correct answer is B) Transparent, red skin. A male infant delivered at 28 weeks gestation weighing 2 pounds, 12 ounces would likely exhibit this characteristic due to the immaturity of his skin. Preterm infants have thinner, transparent skin with visible vasculature, giving it a red appearance due to the presence of capillaries close to the surface. Option A) Wide, staring eye is incorrect because newborns, especially preterm infants, often have difficulty focusing their eyes and may exhibit a lack of coordination in eye movements. This is not a specific finding related to prematurity. Option C) An absence of lanugo is incorrect as lanugo, the fine hair that covers a fetus, is typically present on preterm infants and sheds later in development. Option D) A scrotum with descended testicles is incorrect as preterm male infants often have undescended testicles due to immaturity. Testicular descent usually occurs later in gestation or after birth. In an educational context, understanding the physical characteristics of preterm infants is crucial for nurses caring for this vulnerable population. Recognizing these unique features allows for appropriate assessment, monitoring, and intervention to promote optimal health outcomes for preterm infants.
Question 5 of 5
The best indication that correct attachment to the breast has occurred is when the:
Correct Answer: B
Rationale: In maternal and reproductive health nursing, understanding correct breastfeeding attachment is crucial for promoting successful breastfeeding outcomes. The best indication that correct attachment to the breast has occurred is when the baby's mouth covers most of the areolar surface (Option B). This is because proper latch and attachment ensure effective milk transfer, prevent nipple soreness, and promote adequate stimulation for milk production. Option A (Baby's tongue is securely on top of the nipple) is incorrect because the baby's tongue should be under the nipple, not on top of it, to effectively compress the milk sinuses and extract milk. Option C (Baby makes frequent loud clucking sounds while nursing at each breast) is incorrect as it does not indicate correct attachment but may suggest poor latch or swallowing issues. Option D (Baby sucks each breast vigorously for five minutes before falling asleep) is incorrect as the duration of sucking alone does not determine correct attachment; it is the positioning and mouth coverage that are key. Educationally, nurses should teach mothers the signs of correct attachment, such as observing the baby's mouth covering most of the areola, hearing audible swallowing, and noting comfort and relaxed body language in the baby. Providing hands-on support and guidance to ensure proper latch can significantly impact breastfeeding success and maternal-infant bonding. Regular assessment and reinforcement of correct attachment techniques are essential to support breastfeeding initiation and maintenance.