ATI RN
Nursing Care of the Newborn Questions
Question 1 of 5
Which of the following findings would be most concerning to the infant nursery nurse performing an initial assessment on an infant born minutes ago?
Correct Answer: A
Rationale: The correct answer is A because an umbilical cord with one artery and two veins is indicative of a congenital anomaly, which can lead to serious health issues such as heart defects or kidney problems. The umbilical cord normally has two arteries and one vein. Option B, a respiratory rate of 35 breaths per minute, is within the normal range for a newborn. Option C, pink body with blue extremities, is a common finding in newborns due to their immature circulatory system. Option D, no retractions or grunting, is a positive sign as retractions and grunting can indicate respiratory distress.
Question 2 of 5
A newborn that is a large-for-gestational-age (LGA) infant is in which percentile(s) for weight?
Correct Answer: C
Rationale: The correct answer is C because a newborn classified as large-for-gestational-age (LGA) is above the 90th percentile for weight based on their gestational age. This means the infant's weight is greater than 90% of other infants of the same gestational age. Choices A and B are incorrect as they indicate being below the 90th percentile, which is not the case for an LGA infant. Choice D is also incorrect as an LGA infant's weight is specifically above the 90th percentile, not between the 10th and 90th percentile.
Question 3 of 5
The nurse is performing a gestational age assessment on a newborn. Which characteristic indicates the greatest gestational maturity?
Correct Answer: B
Rationale: The correct answer is B because peeling and cracking of the skin, known as desquamation, is characteristic of a newborn born at term or post-term. This indicates the skin has been in contact with amniotic fluid for an extended period, typical of a more mature gestational age. Choices A, C, and D are incorrect as they do not specifically indicate gestational maturity. Arms and legs extended (A) can be seen in preterm infants. Few rugae on the scrotum and high testes (C) can be normal variations in newborns. The arm positioning (D) does not provide a direct indicator of gestational age.
Question 4 of 5
The nurse is receiving shift report on her mother-baby couplet assignment. Which infant should the nurse evaluate first?
Correct Answer: C
Rationale: The correct answer is C, to evaluate the 40-weeks' gestation female newborn with reported poor feed at the last attempt first. This choice should be prioritized as poor feeding in a newborn can be a sign of potential serious issues such as inadequate nutrition, dehydration, or underlying medical conditions. Addressing this concern promptly is crucial for the infant's well-being. Option A can be considered as the blood sugar level of 60 mg/dL in the 38-weeks' gestation female newborn is slightly low, but it is not an immediate priority compared to poor feeding. Option B's axillary temperature of 37.2°C is within the normal range for a newborn, so it can be assessed after addressing the concern of poor feeding. Option D, a 39-weeks' gestation male newborn crying prior to the initial bath, can also be evaluated after addressing the more urgent issue of poor feed.
Question 5 of 5
The mother-baby nurse is providing care to a patient and her newborn 2 hours after delivery. On review of the newborn's chart, the nurse sees a notation of caput succedaneum. What will the nurse expect to find in the mother's chart?
Correct Answer: B
Rationale: The correct answer is B: A longer than usual labor. Caput succedaneum is swelling of the baby's scalp due to pressure during labor. This indicates a longer labor duration. A: Race is not a factor in the development of caput succedaneum. C: Administration of an epidural does not directly cause caput succedaneum. D: Delivery by cesarean birth is not associated with caput succedaneum.