ATI RN
Nursing Care of the Newborn and Family Questions
Question 1 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 2 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 3 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.
Question 4 of 5
The nurse would expect a physician to prescribe which medication to a postpartum client with heavy bleeding and a boggy uterus?
Correct Answer: C
Rationale: In the scenario described, the correct medication that the physician would prescribe to a postpartum client with heavy bleeding and a boggy uterus is option C) Methylergonovine maleate (Methergine). Methylergonovine is a uterotonic medication that helps to stimulate uterine contractions, leading to decreased bleeding and firming up of the uterus, which is essential in managing postpartum hemorrhage due to uterine atony. Option A) Docusate (Colace) is a stool softener used to prevent constipation, which is not relevant in this situation. Option B) Terbutaline (Brethine) is a tocolytic agent used to stop premature labor contractions, not indicated for postpartum hemorrhage. Option D) Rh immune globulin (RhoGAM) is administered to Rh-negative mothers to prevent Rh incompatibility issues with the baby, not indicated for postpartum hemorrhage. In an educational context, understanding the rationale behind the choice of Methylergonovine in this scenario highlights the importance of recognizing and promptly treating postpartum hemorrhage, a critical complication that can occur after childbirth. Nurses caring for postpartum clients should be aware of the appropriate medications used to manage this condition and understand their mechanisms of action to provide optimal care and prevent complications.
Question 5 of 5
During a postpartum examination of a client who delivered an 8-pound newborn 6 hours ago, the following assessment findings are noted: fundus firm and at the umbilicus, and moderate lochia rubra with a steady trickle of blood from the vagina. What is the assessment finding that would necessitate follow-up?
Correct Answer: B
Rationale: In this scenario, the assessment finding that necessitates follow-up is option B) Steady trickle of blood. This finding indicates excessive bleeding, which could be a sign of postpartum hemorrhage (PPH), a serious complication that requires immediate medical attention. Option A) Firm fundus is a normal finding indicating uterine contraction, and the fundus being at the umbilical level (Option D) is also normal within the first 6 hours postpartum. Option C) Moderate lochia rubra is expected in the early postpartum period as the uterus sheds the decidua and other tissues. Educationally, it is crucial for nursing students to understand the normal postpartum assessment findings and recognize abnormal signs that require prompt intervention. Recognizing the signs of PPH and understanding the urgency of addressing excessive bleeding is essential for providing safe and effective care to postpartum clients and ensuring positive outcomes for both the mother and newborn.