ATI RN
Nursing Care of the Newborn Questions
Question 1 of 5
The nurse determines the fundus of a postpartum client to be boggy. Initially, what should the nurse do?
Correct Answer: B
Rationale: In this scenario, the correct initial action for the nurse to take when determining a boggy fundus in a postpartum client is to choose option B: massage the uterine fundus until it is firm. This intervention is crucial to prevent postpartum hemorrhage, a common complication after childbirth. By massaging the uterine fundus, the nurse helps the uterus contract, which reduces the risk of excessive bleeding. Option A, documenting the findings, is not the priority when immediate intervention is required to address a potentially life-threatening situation like postpartum hemorrhage. Option C, catheterizing the client, is not indicated unless there are specific urinary retention issues, which are not described in the question. Option D, calling the physician immediately, can be necessary after massaging the fundus if the bleeding persists or if there are other concerning signs, but it is not the initial step. Educationally, it is essential for nursing students to understand the significance of assessing and managing postpartum complications promptly. Teaching the correct techniques for uterine massage and emphasizing the importance of early intervention can help students develop critical thinking skills and clinical judgment in managing postpartum care effectively.
Question 2 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 3 of 5
A woman who has just delivered has decided to bottle feed her full term infant. Which of the following should be included in the patient teaching?
Correct Answer: B
Rationale: In the context of nursing care of the newborn, the correct answer is B) You should prepare enough bottles for 24 hours of feedings. This is because it is essential for the mother to have an adequate supply of bottles ready to feed the newborn promptly, ensuring timely and consistent feeding schedules, which are crucial for the baby's growth and development. Option A is incorrect because heating the baby's bottle in the microwave can create hot spots in the liquid, posing a burn risk to the baby's mouth. It is safer to use a bottle warmer or warm water to heat the bottle. Option C is incorrect because bottle nipples should be chosen based on the baby's age and feeding needs. Enlarging the nipple arbitrarily can lead to feeding difficulties and potentially cause choking hazards for the infant. Option D is incorrect because the description of the baby's stools appearing bright yellow and smelling like sour milk is more indicative of breastfed infants due to the composition of breast milk, not formula-fed babies. Educationally, it is crucial to emphasize the importance of proper bottle preparation, storage, and feeding techniques to ensure the newborn's well-being and proper nutrition. Encouraging mothers to plan and prepare an adequate supply of bottles in advance can help establish a smooth feeding routine and promote bonding between the mother and the newborn.
Question 4 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 5 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.