ATI RN
Nursing Care of the Newborn Questions
Question 1 of 5
The most effective time to initiate breast-feeding is in which stage of reactivity for the neonate?
Correct Answer: B
Rationale: The correct answer is B: first period of reactivity. During this stage, the infant is alert and eager to suckle, making it an optimal time to initiate breastfeeding. The infant's sucking reflex is strong, and they are more likely to latch on successfully. The other choices are incorrect because during the period of decreased reactivity (A), the infant is often drowsy and less interested in feeding. The second period of reactivity (C) may involve increased activity and may not be the best time to introduce breastfeeding. After the end of the second period of reactivity (D), the infant may be more settled and not as ready to breastfeed as during the first period of reactivity.
Question 2 of 5
After birth, the nurse immediately dries a neonate's face and hair with a clean, prewarmed towel. After drying, the nurse covers the neonate's hair with a cap. What type of heat loss is the nurse preventing?
Correct Answer: C
Rationale: The correct answer is C: evaporation. After birth, drying the neonate's face and hair with a towel and covering the hair with a cap prevents heat loss through evaporation. Evaporation occurs when moisture on the skin evaporates into the air, leading to cooling of the body. By drying the neonate's hair and covering it with a cap, the nurse reduces the potential for heat loss through evaporation, helping to maintain the neonate's body temperature. Incorrect choices: A: Convection - Heat transfer through the movement of air or liquid. Drying and covering the hair do not directly impact convection heat loss. B: Conduction - Heat transfer through direct contact with a cooler surface. Drying and covering the hair with a cap do not address conduction heat loss. D: Radiation - Heat transfer through electromagnetic waves. Drying and covering the hair do not specifically target radiation heat loss.
Question 3 of 5
What characteristics are directly related to the newborn's decreased ability to maintain thermal stability?
Correct Answer: A
Rationale: Step-by-step rationale: 1. Subcutaneous fat provides insulation, so decreased fat leads to heat loss. 2. A larger body surface-to-weight ratio means more heat loss through the skin. 3. Both factors contribute to the newborn's decreased ability to maintain thermal stability. 4. Blood vessels being farther from the skin (choice B) does not impact thermal stability directly. 5. Brown adipose tissue (choice C) is actually important for heat production in newborns. 6. Constant motion (choice D) may increase heat loss but is not a primary factor in thermal stability for newborns.
Question 4 of 5
The nurse is completing an initial assessment of the newborn. The newborn's ears appear to be parallel to the outer and inner canthus of the eye. How does the nurse document the ear placement?
Correct Answer: C
Rationale: Step 1: Observe the newborn's ears are parallel to the outer and inner canthus of the eye. Step 2: Compare the observed ear placement to the standard positioning. Step 3: If the ears align with the eye canthus, document as "a normal position" (Choice C). Rationale: Parallel ear position indicates normal development. Low set (Choice A) or high set (Choice B) ears suggest abnormalities. Facial paralysis (Choice D) is not related to ear placement in this context.
Question 5 of 5
During an assessment of a 12-hour-old newborn, the nurse notices pale pink spots on the nape of the neck. How does the nurse document this finding?
Correct Answer: D
Rationale: The correct answer is D: telangiectatic nevi. These are also known as "stork bites" or "angel kisses." The rationale for this choice is that telangiectatic nevi are pale pink spots commonly found on the nape of the neck in newborns, which typically fade over time. A: Nevus vasculosus is a different type of birthmark characterized by a red or purple color due to an overgrowth of blood vessels. B: Mongolian spots are bluish-gray birthmarks usually found on the lower back or buttocks. C: Nevus flammeus, also known as a port-wine stain, presents as a flat, pink, or red mark on the skin. In summary, the correct answer, telangiectatic nevi, is the most appropriate choice based on the description of the finding on the newborn's nape of the neck, while the other options describe different types of birthmarks with distinct characteristics.