ATI RN
Nursing Care of the Newborn Questions
Question 1 of 5
The nurse assesses four newborns. Which of the following assessment findings would place a newborn at risk for developing physiologic jaundice?
Correct Answer: C
Rationale: In the context of pharmacology and nursing care of the newborn, understanding the risk factors for developing physiologic jaundice is essential for providing safe and effective care. Physiologic jaundice occurs when there is an accumulation of bilirubin in the newborn's blood, leading to yellowing of the skin and eyes. In this case, the correct answer is C) Cephalohematoma. Cephalohematoma is a collection of blood between a newborn's skull and the periosteum, often caused by birth trauma. When blood breaks down, it releases bilirubin, increasing the risk of hyperbilirubinemia and physiologic jaundice. A) Mongolian spots are benign birthmarks common in newborns of darker skin tones and do not contribute to jaundice. B) Molding refers to the shaping of the baby's head during childbirth and is not directly related to jaundice. D) Telangiectatic nevi are vascular birthmarks and do not increase the risk of physiologic jaundice. Educationally, this question highlights the importance of recognizing physical findings that may indicate an increased risk of physiologic jaundice in newborns. Nurses must be able to differentiate between normal variations and potential risk factors to provide timely interventions and prevent complications associated with jaundice.
Question 2 of 5
The nurse is assessing the laboratory report on a 2-day post partum. The woman has had a normal post partum assessment this morning. Which of the following results should the nurse report to the provider?
Correct Answer: C
Rationale: In this scenario, the correct answer is option C) Hematocrit 26%. The postpartum period is a critical time for monitoring a woman's blood values due to the physiological changes that occur after childbirth. A hematocrit level of 26% indicates a lower than normal red blood cell count, which could suggest postpartum hemorrhage or anemia, both of which require immediate medical attention to prevent complications. Option A) White blood cells 12,500 cells/mm is within normal limits and not typically a cause for concern in the immediate postpartum period. Option B) Red blood cells 4,500,000 cells/mm is also within normal range and not alarming. Option D) Hemoglobin 11g/dl is slightly low but not as concerning as a low hematocrit level, as hemoglobin levels can be affected by factors such as hydration status. Educationally, understanding the significance of specific laboratory values in the postpartum period is crucial for nurses caring for newborns and their mothers. This knowledge enables early identification of potential complications and prompt intervention, ensuring optimal maternal and neonatal outcomes.
Question 3 of 5
The nursery nurse notes the presence of diffuse edema on a newborn babys head. Review of the birth record indicates that her mother experienced a prolonged labor and difficult childbirth. What action by the nurse is best?
Correct Answer: A
Rationale: The correct answer is A) Document the findings in the infant's chart. In this scenario, the presence of diffuse edema on the newborn's head is likely due to the prolonged labor and difficult childbirth experienced by the mother. This condition is often transient and can be attributed to molding of the baby's head during the birth process. Documenting this finding in the infant's chart is crucial for accurate and comprehensive medical record-keeping. It allows for continuity of care, facilitates communication among healthcare providers, and ensures that the baby's condition is properly monitored and managed. Measuring head circumference every 12 hours (option B) may not be necessary as the edema is most likely a temporary issue related to birth trauma. Administering IV osmotic diuretics (option C) is not indicated as edema in this context does not typically require pharmacological intervention. Transferring the baby to the NICU for monitoring (option D) is not warranted unless there are other concerning symptoms or issues beyond the diffuse edema. Educationally, understanding the physiological processes that newborns go through during birth and the common variations in appearance and conditions that may arise is essential for nurses caring for newborns. Proper documentation and assessment skills are fundamental in providing safe and effective care to ensure the well-being of newborns and support their healthy transition to life outside the womb.
Question 4 of 5
The perinatal nurse wants to contact the pediatrician about a heart murmur that was auscultated during a newborn assessment. During what time frame would hearing the murmur lead the nurse to contact the health-care provider?
Correct Answer: D
Rationale: The correct answer is D) 48 to 72 hours. In the context of a newborn assessment, a heart murmur detected within the first 48 to 72 hours after birth is considered significant and warrants prompt evaluation by a healthcare provider. This timeframe is crucial because certain types of heart murmurs in newborns can indicate underlying congenital heart defects that may require immediate intervention or monitoring. Option A) 8 to 12 hours is too soon to make a definitive assessment of the heart murmur in a newborn. Option B) 12 to 24 hours is also early in the postnatal period and may not allow for a comprehensive evaluation of the murmur. Option C) 24 to 48 hours is closer to the correct timeframe, but it is still within the critical period where a timely assessment is necessary to rule out any serious cardiac issues in the newborn. Understanding the importance of timely detection and evaluation of heart murmurs in newborns is vital for perinatal nurses as they play a crucial role in identifying potential health concerns early and facilitating appropriate interventions. This knowledge ensures the optimal care and outcomes for newborns with cardiac issues, emphasizing the significance of ongoing assessment and communication with healthcare providers in the early postnatal period.
Question 5 of 5
In order to promote thermal stabilization in a neonate
Correct Answer: B
Rationale: In the context of nursing care for newborns, promoting thermal stabilization is crucial to prevent hypothermia and maintain physiological stability. The correct answer, option B, to lay the infant in an incubator, is the best action to achieve thermal stabilization. Incubators provide a controlled environment with regulated temperature, humidity, and oxygen levels, ensuring the neonate's body temperature is maintained within the optimal range. Option C, placing the infant in skin-to-skin contact with the mother, is a beneficial practice for bonding and breastfeeding initiation. While skin-to-skin contact offers emotional benefits, it may not provide adequate thermal stabilization for a neonate at risk of hypothermia. Option D, putting a knitted cap on the baby's head, is a helpful measure to reduce heat loss from the head. However, it is not as effective as placing the infant in an incubator, which offers comprehensive thermal regulation for the entire body. In the educational context, understanding the importance of thermal stabilization in neonates is fundamental for nursing care. Nurses must be aware of the appropriate interventions to maintain newborns' body temperature within the normal range to support their overall well-being and prevent complications associated with heat loss. The use of an incubator is a standard practice in neonatal care units to promote thermal stability and ensure optimal outcomes for newborns.