ATI RN
Nursing Care of the Newborn Questions
Question 1 of 5
The nurse holds an infant upright and allows his feet to brush the surface of the examination table. Which of the following is the normal reflex response to this stimulation?
Correct Answer: C
Rationale: The stepping reflex occurs when the infant is held upright and his or her feet brush a horizontal surface distal to the feet. Drawing the legs up tight against the lower abdomen would be an abnormal response. Extending the legs against pressure is a positive magnet reflex. Curling the toes in, then fanning them outward, is a positive Babinski reflex.
Question 2 of 5
A nurse has just been asked to be the baby nurse for a coworker who is working with a birthing woman at 35 weeks, 3 days. The patient has preeclampsia, has had a very hard labor with multiple decelerations on her fetal heart monitor, and her amniotic fluid had meconium when her water was broken earlier in the day. In anticipation of this birth, what resources will the nurse need to gather? Select all that apply.
Correct Answer: B
Rationale: In this scenario, the correct answer is B) Neonatal Intensive Care team. The presence of preeclampsia, fetal distress, and meconium-stained amniotic fluid indicate potential complications during the birth that may require immediate intervention from a specialized neonatal team. This team is equipped to handle emergent situations and provide the necessary care for a newborn in distress. Option A) another baby nurse to help is incorrect as the primary concern in this situation is the need for specialized neonatal care, not additional nursing support. While having extra help is beneficial, it is not the priority. Option C) radiant warmer for the newborn is not the most critical resource to gather in this high-risk situation. While a radiant warmer may be needed for thermoregulation, the immediate focus should be on ensuring access to specialized medical care. Option D) intubation kit is not the most appropriate resource to gather preemptively in this case. While intubation may become necessary in the event of respiratory distress, the presence of a Neonatal Intensive Care team would be better equipped to handle such interventions. In an educational context, this question highlights the importance of anticipating and preparing for potential complications during the birth process, especially in high-risk situations like preeclampsia and fetal distress. It emphasizes the critical role of specialized neonatal care in ensuring the best possible outcomes for both the mother and the newborn.
Question 3 of 5
The most effective time to initiate breast-feeding is in which stage of reactivity for the neonate?
Correct Answer: B
Rationale: In the context of pharmacology and nursing care of the newborn, the most effective time to initiate breastfeeding is during the first period of reactivity for the neonate, which is typically within the first hour of birth. This period is characterized by increased alertness and sucking reflex, making it an optimal time for successful breastfeeding initiation. Choosing option B as the correct answer is supported by the fact that newborns are most alert and responsive during the first period of reactivity, which enhances their ability to latch onto the breast and start breastfeeding successfully. This early initiation is crucial for establishing a good breastfeeding relationship between the mother and the newborn, promoting bonding, providing essential nutrients, and supporting the baby's overall health and development. Options A, C, and D are incorrect because they do not align with the physiological characteristics of the newborn during the different stages of reactivity. During the period of decreased reactivity (option A), the newborn is typically quiet and less responsive, which may not be conducive to effective breastfeeding initiation. The second period of reactivity (option C) occurs later and is characterized by another surge of activity, which may not be the ideal time for breastfeeding initiation. Choosing to breastfeed after the end of the second period of reactivity (option D) may miss the window of opportunity when the newborn is most alert and eager to breastfeed. Understanding the timing of breastfeeding initiation in relation to the newborn's stages of reactivity is essential for nurses caring for newborns to support successful breastfeeding outcomes and promote the well-being of both the baby and the mother. By recognizing the optimal time for breastfeeding initiation, healthcare providers can contribute to establishing a strong foundation for newborn care and promoting positive health outcomes in the neonatal period and beyond.
Question 4 of 5
What assessment findings indicate abnormal transition in a neonate? Select all that apply.
Correct Answer: C
Rationale: In the context of pharmacology and nursing care of the newborn, understanding the assessment findings that indicate abnormal transition in a neonate is crucial for providing appropriate care. Excessive oral secretions (Option C) are indicative of abnormal transition in a neonate. This can suggest potential issues with swallowing or respiratory function, warranting further evaluation and intervention. Prolonged apneic episodes (Option A) can also be concerning in a newborn but may not specifically indicate abnormal transition. It could be related to other factors such as immaturity of the respiratory center or underlying medical conditions. Marked pallor (Option B) can be a sign of anemia or circulatory issues rather than directly related to the transition phase in a neonate. Crackles upon auscultation (Option D) may indicate respiratory issues like pneumonia but may not be specific to abnormal transition in a newborn. Educationally, nurses need to be able to differentiate between normal and abnormal findings in a newborn to provide timely and appropriate care. Understanding these assessment findings helps in early identification of potential problems and ensures optimal care for neonates.
Question 5 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: In this scenario, the correct answer is C) evaporation. When the nurse dries the neonate's hair and covers it with a cap, they are preventing heat loss through evaporation. Evaporation is a significant source of heat loss for newborns because their skin is thin and they have a large surface area in relation to their body weight. By covering the neonate's wet hair with a cap, the nurse is creating a barrier that reduces the evaporation of moisture from the hair, thus helping to maintain the baby's body temperature. Convection (A), conduction (B), and radiation (D) are not the types of heat loss being prevented in this specific situation. Convection involves the transfer of heat through air or water currents, which is not addressed by drying the baby's hair. Conduction refers to the transfer of heat through direct contact with a cooler surface, which is not the case when the nurse is drying and covering the hair. Radiation is the transfer of heat in the form of electromagnetic waves, which is also not applicable when the nurse is managing evaporation. This practice is essential in newborn care as maintaining the baby's body temperature is crucial for their well-being and overall health. By understanding the mechanisms of heat loss and how to prevent them effectively, nurses can provide optimal care to newborns and support their thermoregulation, which is particularly important in the vulnerable postnatal period.