ATI RN
Nursing Care of the Newborn and Family Questions
Question 1 of 5
The nurse is teaching a postpartum patient different holds for breastfeeding. Which of the following figures depicts the football hold frequently used for patients who have had a cesarean birth?
Correct Answer: B
Rationale: The correct answer is B because the football hold is a breastfeeding position where the baby is positioned at the side of the mother, with the baby's legs tucked under the mother's arm. This position is beneficial for mothers who have had a cesarean birth as it keeps the baby away from the incision site. Choice A does not show the baby tucked under the arm, choices C and D show the baby positioned differently than in the football hold. Therefore, B is the correct choice for the football hold commonly used for postpartum patients who have had a cesarean birth.
Question 2 of 5
Of the three fetal shunts, which one moves fetal blood from the lungs through the right atrium to the left atrium?
Correct Answer: B
Rationale: The correct answer is B: foramen ovale. The foramen ovale is a shunt that allows blood to bypass the fetal lungs by connecting the right atrium to the left atrium. This is important in utero to ensure oxygenated blood goes directly to the body. The other options are incorrect because: A: Ductus venosus - connects the umbilical vein to the inferior vena cava, bypassing the liver. C: Ductus arteriosus - connects the pulmonary artery to the aorta, bypassing the fetal lungs. D: Foramen venosus - does not exist; it is not a fetal shunt.
Question 3 of 5
A newborn at 20 minutes of age has an axillary temperature of 36° C (96.8° F). What intervention should the nurse perform?
Correct Answer: A
Rationale: The correct answer is A: ensure skin-to-skin contact until temperature is 37°C (98.6°F). Skin-to-skin contact helps regulate the baby's temperature by utilizing the parent's body heat. This method is gentle and effective in stabilizing the baby's temperature without the risk of overheating or cooling too quickly. It promotes bonding and breastfeeding initiation. Choice B is incorrect because giving the baby a warm bath may lead to overheating and should not be done for a newborn with a slightly low temperature. Choice C is incorrect because using a radiant warmer may be too aggressive for a mild temperature drop. Choice D is incorrect because rectal temperature checking is invasive and unnecessary at this point.
Question 4 of 5
The nurse is caring for a neonate born at 36 weeks, 2 days by primary cesarean birth and weighing 6 pounds, 4 ounces. The infant cried at delivery, had flexion in all extremities, had a heart rate of 135, had acrocyanosis in hands and feet, and was pale. The infant was placed skin-to-skin with the birthing person and has been latching and cuddling for the past 15 minutes. At 45 minutes, the neonate is found grunting and cool to the touch. What are the nurse's next steps?
Correct Answer: C
Rationale: The correct answer is C: Take the neonate to the radiant warmer and check their temperature. This is the appropriate next step because the neonate is showing signs of potential respiratory distress (grunting) and coolness to the touch, which could indicate hypothermia. Placing the neonate in the radiant warmer will help maintain a stable temperature and facilitate further assessment and intervention. Choice A is incorrect because stimulating the neonate to take deep breaths may not address the underlying issue of potential respiratory distress. Choice B is incorrect because simply wrapping the baby in blankets and cuddling them closer may not address the potential respiratory distress or hypothermia that the neonate is exhibiting. Choice D is incorrect because calling the NICU staff and activating the staff assist light should be done after assessing the neonate's immediate needs, such as addressing potential respiratory distress and hypothermia.
Question 5 of 5
A new parent asks the nurse why the 36-hour-old newborn has a yellow skin tint. What should the nurse explain to the parent?
Correct Answer: D
Rationale: The correct answer is D because physiologic jaundice is a normal condition in newborns due to the breakdown of fetal red blood cells. Bilirubin, a byproduct of this breakdown, causes the yellow skin tint. The liver is still developing in newborns, so it may take some time for it to process and eliminate the excess bilirubin. Choice A is incorrect because it implies liver dysfunction, which is not the case in physiologic jaundice. Choice B is incorrect as yellow skin does not indicate brain damage. Choice C is incorrect because bilirubin is primarily excreted through the liver, not the bowels, in newborns.