ATI RN
Nursing Care of the Newborn Quizlet Questions
Question 1 of 5
Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot?
Correct Answer: A
Rationale: The correct answer is A: Babinski reflex. This reflex is elicited by stroking the lateral sole of the infant's foot, causing the big toe to extend and the other toes to fan out. This response is normal in infants up to 2 years old. The other choices are incorrect because: B: Stepping reflex is the automatic movement of the legs when held upright with the feet touching a surface. C: Tonic neck reflex occurs when an infant turns their head to one side, the arm on that side extends while the opposite arm flexes. D: Plantar grasp reflex is when pressure is applied to the sole of the foot, causing the toes to curl.
Question 2 of 5
Which nursing action is designed to avoid unnecessary heat loss in the newborn?
Correct Answer: B
Rationale: The correct answer is B because placing a blanket over the scale before weighing the infant helps prevent unnecessary heat loss by keeping the baby warm during the process. This action maintains the baby's body temperature and reduces the risk of hypothermia. A: Maintaining room temperature at 21°C may not be sufficient to prevent heat loss during specific procedures. C: Taking rectal temperature every hour is not necessary and may expose the baby to unnecessary heat loss. D: Undressing the infant completely for assessments can lead to rapid heat loss and should be avoided to maintain the baby's body temperature.
Question 3 of 5
Which assessment finding of a newborn requires prompt action by the nurse?
Correct Answer: C
Rationale: The correct answer is C: Pause in breathing lasting 20 seconds. This finding indicates a potential apnea episode in the newborn, which requires immediate attention to prevent further complications like hypoxia. The pause in breathing lasting 20 seconds exceeds the normal range for apnea in newborns, typically defined as a pause lasting more than 15 seconds. Prompt action is necessary to assess and address the underlying cause of the apnea episode. Choice A (Respiratory rate of 50 breaths per minute) is within the normal range for newborns (30-60 breaths per minute) and does not require immediate action. Choice B (Cyanosis of the extremities) may indicate poor circulation but is not as urgent as a prolonged pause in breathing. Choice D (Pause in breathing for 15 seconds followed by rapid respirations) is incorrect as it does not meet the criteria for apnea in newborns and does not require immediate action.
Question 4 of 5
The nurse is performing the initial assessment of a newborn and notes retractions, nasal flaring, and tachypnea. The nurse will continue to perform a focused assessment on which system?
Correct Answer: A
Rationale: The correct answer is A: Respiratory. Retractions, nasal flaring, and tachypnea are signs of respiratory distress in a newborn. The nurse should focus on the respiratory system to assess the baby's breathing, lung sounds, oxygen saturation, and overall respiratory status. This is crucial for identifying any potential respiratory issues and providing prompt interventions. Choices B, C, and D are incorrect because the symptoms described are specific to respiratory distress and do not indicate cardiovascular, gastrointestinal, or musculoskeletal issues. Focusing on these systems would not address the immediate concern of respiratory distress in the newborn.
Question 5 of 5
An infant at term was born at 0105 hours. The nurse is developing a plan of care for the newborn. During which time range will the nurse plan on performing the assessment to determine a Ballard score?
Correct Answer: B
Rationale: The correct answer is B (0200 to 0600) because the Ballard score is typically assessed within the first 12-24 hours of life. Given that the infant was born at 0105 hours, the nurse should plan on performing the assessment between 0200 to 0600. This time frame falls within the recommended window for assessing the Ballard score accurately. Choices A, C, and D are incorrect because they fall outside the optimal time range for conducting the assessment. Option A (0115 to 0130) is too soon after birth, and options C (1400 to 1800) and D (2000 to 2300) are too late for the initial assessment as per standard practice.