ATI RN
Nursing Care of the Newborn and Family Questions
Question 1 of 5
The nurse is assessing a newborn's reflexes. Which response will cause the nurse concern?
Correct Answer: C
Rationale: The correct answer is C: Asymmetrical Moro reflex. This is concerning because the Moro reflex should be symmetrical, with both arms and legs extending and then flexing in response to a sudden movement or loud noise. An asymmetrical Moro reflex could indicate a neurological issue or injury. A: A fencing position when the head is turned is a normal response indicating a healthy neurological function. B: A strong Babinski reflex is normal in infants and can indicate a healthy nervous system development. D: The absence of rooting or sucking reflexes can be a concern but is not as immediate as an asymmetrical Moro reflex.
Question 2 of 5
The nurse is providing information to a postpartum mother about circumcision of her neonate. The neonate's father states, 'We have never done that to any baby boy in my family.' Which statement is best for the nurse to make?
Correct Answer: D
Rationale: Rationale for Correct Answer D: 1. Acknowledges father's statement without judgment. 2. Shows empathy and understanding towards family beliefs. 3. Promotes respect for cultural diversity and individual choices. 4. Encourages open dialogue and shared decision-making. 5. Reflects a patient-centered approach to care. Summary of Incorrect Choices: A: Assumes most families opt for circumcision without considering individual preferences. B: Passively offers information without addressing father's concerns. C: Imposes personal opinion on father's decision-making process, disregarding cultural beliefs.
Question 3 of 5
The breastfeeding patient should be taught a safe method to remove her breast from the baby's mouth. Which suggestion by the nurse is most appropriate?
Correct Answer: A
Rationale: Rationale for correct answer (A): 1. Breaking the suction by inserting a finger into the corner of the infant's mouth is the most appropriate method to remove the breast safely. 2. This technique prevents trauma to the nipple and helps the baby release the latch gently. 3. It allows for a smooth and painless disengagement of the baby from the breast. 4. By breaking the suction first, the risk of causing discomfort or injury to both the mother and the baby is minimized. Summary of why other choices are incorrect: B. A popping sound is not a reliable indicator of correct breast removal and may lead to abrupt disengagement, causing pain and potential injury. C. Removing the breast slowly while the baby is asleep can disrupt the baby's sleep and may not be gentle or safe. D. Eliciting the Moro reflex is unnecessary and may startle the baby, leading to an abrupt disengagement that can cause discomfort and potential injury.
Question 4 of 5
Which type of formula should not be diluted before being administered to an infant?
Correct Answer: C
Rationale: The correct answer is C: Ready to use. Ready to use formula should not be diluted before being administered to an infant because it is already in the appropriate concentration for consumption. Diluting it further could result in the infant not receiving the necessary nutrients in the right proportions, potentially leading to nutritional deficiencies or other health issues. Explanation of why other choices are incorrect: A: Powdered formulas are designed to be mixed with water according to specific instructions provided by the manufacturer, so they should be diluted before administering to an infant. B: Concentrated formulas are meant to be mixed with water before feeding to the infant, so they should be diluted as per the instructions. D: Modified cow's milk should be diluted as it is not suitable for infants in its concentrated form and needs to be appropriately prepared according to guidelines provided by healthcare professionals.
Question 5 of 5
Which recommendation should the nurse make to a patient to assist in initiating the milk-ejection reflex?
Correct Answer: C
Rationale: The correct answer is C: Place the infant to the breast. This recommendation is correct because direct breastfeeding stimulation is the most effective way to initiate the milk-ejection reflex. The infant's sucking triggers the release of oxytocin, which causes the muscles around the milk ducts to contract and push milk out. Wearing a well-fitting firm bra (choice A) may provide support but does not directly stimulate the milk-ejection reflex. Drinking plenty of fluids (choice B) is important for overall milk production but does not specifically help initiate the reflex. Applying cool packs to the breast (choice D) may actually hinder milk flow by constricting blood vessels.