ATI RN
Nursing Care of the Newborn and Family Questions
Question 1 of 5
When thinking about scoring an Apgar assessment, the nurse knows that grimace is an assessment of what in a newborn?
Correct Answer: D
Rationale: In the context of scoring an Apgar assessment, the correct answer is D) Grimace is an assessment of the response to stimulation from the nurse. Apgar scores evaluate a newborn's physical condition at 1 and 5 minutes after birth. The "grimace" component assesses the newborn's reflex irritability or response to stimulation, such as gently stroking the newborn's back. This response indicates the normal development of the central nervous system. Option A) is incorrect because the Apgar assessment does not specifically evaluate the newborn's response to taking their first breath. Option B) is incorrect as it describes a different assessment related to the flexion of hips and legs. Option C) is also incorrect as the Apgar assessment focuses on physiological responses rather than emotional or visual stimuli. Understanding the components of the Apgar assessment is crucial for nurses caring for newborns as it helps in quickly evaluating and addressing any potential issues in the newborn's transition to extrauterine life. Nurses must be able to accurately interpret Apgar scores to provide prompt and appropriate interventions for newborns in need of support.
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: In fetal circulation, the foramen ovale is the fetal shunt that allows blood to bypass the nonfunctional lungs by moving from the right atrium to the left atrium. This shunt is crucial for directing oxygenated blood to the systemic circulation while bypassing the pulmonary circulation, which is unnecessary in the fetal environment. The incorrect options are as follows: A) Ductus venosus: This shunt bypasses the liver, directing partially oxygenated blood from the umbilical vein to the inferior vena cava. C) Ductus arteriosus: This shunt allows blood to bypass the fetal lungs by connecting the pulmonary artery to the aorta. D) Foramen venosus: This is a distractor as it is not a valid anatomical structure. Understanding fetal circulation is essential for healthcare professionals, especially nurses caring for newborns. Knowledge of fetal shunts helps in assessing newborns for potential cardiac issues and in understanding the transition from fetal to neonatal circulation. Recognizing the foramen ovale's function is critical for providing appropriate care to newborns with cardiac anomalies related to these shunts.
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: In this scenario, the correct intervention for the nurse to perform is to ensure skin-to-skin contact until the newborn's temperature reaches 37°C (98.6°F). This is the correct answer because skin-to-skin contact is a safe and effective way to help regulate a newborn's body temperature. The warmth from the parent's skin helps the baby to maintain a stable temperature, promoting thermoregulation and reducing the risk of hypothermia. Option B, giving the baby a warm bath and then returning to the birthing parent for skin-to-skin contact, is incorrect because exposing the newborn to a warm bath may further decrease their body temperature, exacerbating the risk of hypothermia. Option C, placing the baby under the radiant warmer until the skin temperature is 37.5°C (99.5°F), is also incorrect as radiant warmers are typically used for infants who are already hypothermic and not as a preventive measure for normal newborns. Option D, checking the baby's rectal temperature, is unnecessary at this point as axillary temperature is an appropriate method for initial temperature assessment in newborns and does not require rectal temperature measurement unless there are specific concerns. Educationally, this scenario highlights the importance of maintaining a newborn's body temperature in the immediate postnatal period. It emphasizes the beneficial effects of skin-to-skin contact in promoting thermal stability and the nurse's role in providing appropriate care to support the newborn's transition to extrauterine life.
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: In this scenario, the correct next step for the nurse is option C, which is to take the neonate to the radiant warmer and check their temperature. This choice is the most appropriate because the neonate is showing signs of potential respiratory distress and hypothermia, which are critical issues that need to be addressed promptly. Option A is incorrect because simply stimulating the neonate to take deep breaths may not address the underlying issue of respiratory distress. Option B is also incorrect as wrapping the baby in blankets and cuddling closer may not adequately address the potential respiratory and temperature concerns. From an educational perspective, this scenario highlights the importance of recognizing signs of respiratory distress and hypothermia in neonates. It emphasizes the need for prompt assessment and intervention to ensure the well-being of the newborn. Understanding these critical signs and appropriate interventions is essential for nurses caring for newborns to provide safe and effective care.
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) The color is a sign of physiologic jaundice, a normal finding. Physiologic jaundice is common in newborns due to the breakdown of fetal red blood cells and the temporary immaturity of the liver in processing bilirubin. This results in a yellow skin tint, usually appearing after the first 24 hours of life. It is a normal and self-limiting condition that does not indicate a serious underlying problem. Option A) The newborn’s liver is not functioning as well as it should is incorrect because physiologic jaundice is not a result of liver dysfunction but rather the normal breakdown of red blood cells. Option B) The yellow color indicates possible brain damage is incorrect as physiologic jaundice does not directly correlate with brain damage. Option C) The infant’s bowels are not excreting bilirubin is incorrect because physiologic jaundice is primarily due to the liver's processing of bilirubin, not the bowel's excretion. It is important for parents to be educated about physiologic jaundice to alleviate concerns and understand the normal variations in newborn appearance and physiology. Monitoring and management by healthcare providers are crucial to ensure bilirubin levels remain within safe limits.