ATI RN
Nursing Care of the Newborn and Family Questions
Question 1 of 5
What kind of muscle tone does a preterm newborn have compared to a full-term newborn?
Correct Answer: D
Rationale: The correct answer is D: flaccid. Preterm newborns typically have lower muscle tone compared to full-term newborns due to their immature nervous system. This results in a lack of firmness or strength in their muscles, leading to a flaccid appearance. Choice A is incorrect because preterm newborns do not have firm muscle tone. Choice B is incorrect as it is too general and does not specify the type of abnormality. Choice C is incorrect because preterm newborns do not have normal muscle tone like full-term newborns.
Question 2 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 3 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 4 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.
Question 5 of 5
A new parent is concerned about a mass on the newborn's head. The nurse assesses this to be a cephalohematoma based on what characteristics?
Correct Answer: B
Rationale: The correct answer is B because a cephalohematoma is a collection of blood between the skull bone and its periosteum. It is usually unilateral and does not cross suture lines. Choice A is incorrect because cephalohematomas do not appear suddenly. Choice C is incorrect as cephalohematomas do not cause the head to feel boggy or cross suture lines. Choice D is incorrect because the mass does not increase in size when the infant cries.