ATI RN
Nursing Care of the Newborn Questions
Question 1 of 5
The nurse is receiving shift report on her mother-baby couplet assignment. Which infant should the nurse evaluate first?
Correct Answer: C
Rationale: The correct answer is C, to evaluate the 40-weeks' gestation female newborn with reported poor feed at the last attempt first. This choice should be prioritized as poor feeding in a newborn can be a sign of potential serious issues such as inadequate nutrition, dehydration, or underlying medical conditions. Addressing this concern promptly is crucial for the infant's well-being. Option A can be considered as the blood sugar level of 60 mg/dL in the 38-weeks' gestation female newborn is slightly low, but it is not an immediate priority compared to poor feeding. Option B's axillary temperature of 37.2°C is within the normal range for a newborn, so it can be assessed after addressing the concern of poor feeding. Option D, a 39-weeks' gestation male newborn crying prior to the initial bath, can also be evaluated after addressing the more urgent issue of poor feed.
Question 2 of 5
The nurse is assessing a newborn and notes a nevus flammeus birthmark. Which of the following figures depicts this birthmark?
Correct Answer: C
Rationale: The correct answer is C because nevus flammeus, also known as a port-wine stain, is a flat, pink, or red birthmark that appears as a patch on the skin. Choice C depicts a birthmark that matches this description. Choice A shows a mole, choice B shows a café-au-lait spot, and choice D shows a strawberry hemangioma, which are different types of birthmarks. So, choice C is the only one that accurately represents a nevus flammeus birthmark.
Question 3 of 5
The postpartum nurse notices that a new mother has her neonate unwrapped and undressed 'to check out the baby.' For which reason does the nurse conclude the neonate is at risk for cold stress?
Correct Answer: D
Rationale: The correct answer is D because cool and clammy skin is a sign of cold stress in neonates. When a neonate's skin is cool and clammy, it indicates that the baby is losing body heat and struggling to maintain a stable body temperature. Cold stress can lead to complications such as hypothermia and respiratory distress. A: Increased metabolic rate would actually help generate heat to combat cold stress. B: Respiratory rate dropping is not necessarily indicative of cold stress and may be a normal response to being undressed. C: Moving extremities about is a normal behavior and not necessarily a sign of cold stress.
Question 4 of 5
The nurse is assessing a term neonate delivered to a mother with a history of drug and alcohol abuse. Which finding does the nurse relate to the mother's history?
Correct Answer: D
Rationale: The correct answer is D because a head circumference below the 10th percentile for gestational age can be indicative of intrauterine growth restriction (IUGR), which is commonly seen in infants of mothers with a history of drug and alcohol abuse. This is due to restricted fetal growth caused by maternal substance abuse. A, B, and C are incorrect: A: Chest circumference being less than head circumference is not directly related to maternal drug and alcohol abuse. B: The neonate's pulse rate increasing when crying is a normal physiological response and is not specific to the mother's history of substance abuse. C: Absence of tear production when crying is not a typical finding related to maternal drug and alcohol abuse.
Question 5 of 5
The nurse is providing care for a neonate during the fourth stage of labor. Which action does the nurse take during this stage?
Correct Answer: A
Rationale: The correct answer is A: Dry the neonate immediately. This is crucial during the fourth stage of labor to prevent hypothermia in the neonate. Drying the neonate helps maintain body temperature and reduce heat loss. Choice B is incorrect because a complete neonate assessment should be done within the first 1-2 minutes, not within 1 hour. Choice C is incorrect as obtaining neonate blood glucose levels is not typically done during the immediate post-birth period unless indicated. Choice D is incorrect as Apgar screening is typically done at 1 and 5 minutes after birth, not until the scores are 7.