ATI RN
Nursing Care of the Newborn and Family Questions
Question 1 of 5
The nurse knows that a full-term newborn presents with ears that include what assessment characteristics?
Correct Answer: B
Rationale: The correct answer is B because a full-term newborn typically has well-curved pinna that is soft and has a ready recoil. This indicates normal ear development and flexibility in newborns. Choice A is incorrect as a slightly curved pinna with slow recoil is not characteristic of a full-term newborn. Choices C and D are incorrect as thick cartilage with a stiff ear or a flat pinna that stays folded are not typical findings in full-term newborns. Therefore, the characteristics described in choice B align with normal ear development in a full-term newborn.
Question 2 of 5
The nurse knows that during the interactive process of the Brazelton assessment, the newborn will receive a poor rating by reacting to what?
Correct Answer: D
Rationale: The correct answer is D because during the Brazelton assessment, crying inconsolably is an indication of the newborn's inability to self-regulate and cope with stimuli, leading to a poor rating. Turning the head towards a familiar voice (A) is a positive response showing recognition. Staying awake (B) may indicate alertness and engagement. Focusing on an object (C) demonstrates visual attention skills. But only crying inconsolably (D) reflects the newborn's distress and poor ability to regulate emotions, leading to a poor rating in the assessment.
Question 3 of 5
When teaching umbilical cord care to a new parent, the nurse would include which information?
Correct Answer: C
Rationale: Step 1: Keeping the cord dry and open to air helps promote natural drying and healing. Step 2: Moisture can lead to infection, so keeping it dry is crucial. Step 3: Covering the cord or applying substances can trap moisture and hinder healing. Step 4: Using peroxide or soap can irritate the delicate skin and disrupt the natural healing process. Summary: Choice C is correct as it promotes optimal cord healing, while the other choices can introduce moisture, irritants, or disrupt the natural healing process.
Question 4 of 5
At 1 minute following birth, the newborn exhibited the following: heart rate of 155; loud, vigorous crying with active movement of all extremities; sneezing when nose is stimulated with a catheter; hands and feet bluish and cool to the touch. The Apgar score of this newborn should be recorded as
Correct Answer: D
Rationale: In this scenario, the correct Apgar score for the newborn at 1 minute following birth is D) 9. The Apgar score assesses the newborn's overall condition at birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. A score of 9 reflects that the newborn is in good to excellent condition. The heart rate of 155 indicates good cardiovascular function, the loud crying and active movement demonstrate good respiratory effort and muscle tone, and the sneezing reflex indicates a healthy response to stimulation. The bluish and cool hands and feet are common in newborns due to their immature circulatory system, and it does not significantly impact the Apgar score at 1 minute. Option A) 1 is incorrect as the newborn's vital signs and responses indicate a much better condition than a score of 1. Option B) 3 is also incorrect as the newborn's presentation is not indicative of a score of 3, which would suggest severe distress. Option C) 18 is not a possible Apgar score, as the maximum score is 10, so it is also incorrect. In an educational context, understanding the Apgar scoring system is crucial for nurses caring for newborns as it helps in quickly assessing their condition and determining the need for immediate interventions. This case highlights the importance of recognizing normal physiological responses in newborns immediately after birth to provide appropriate care and support.
Question 5 of 5
When caring for a newborn, the nurse must be alert for signs of cold stress, including:
Correct Answer: B
Rationale: In caring for a newborn, being alert for signs of cold stress is crucial to prevent complications. The correct answer, option B - Decreased activity level, is indicative of cold stress in a newborn. When a newborn is cold, they may conserve energy by decreasing their activity level to maintain body temperature. This is a physiological response aimed at conserving heat and energy. The other options are incorrect: - Option A) Increased respiratory rate is more commonly associated with conditions like respiratory distress, not specifically cold stress. - Option C) Hyperglycemia is not a typical sign of cold stress in a newborn. - Option D) Shivering is a sign of extreme cold stress and is a late sign in newborns. Before shivering, newborns tend to exhibit signs like decreased activity level. Educationally, understanding the signs of cold stress in newborns is vital for nurses to provide appropriate care and prevent complications like hypothermia. Recognizing these signs early can help nurses intervene promptly by providing warmth and monitoring the newborn closely to maintain their body temperature within a safe range.