While assisting with the care of an infant with a high bilirubin level receiving phototherapy, which finding should the nurse prioritize for reporting to the charge nurse?

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ATI Maternal Newborn Questions

Question 1 of 5

While assisting with the care of an infant with a high bilirubin level receiving phototherapy, which finding should the nurse prioritize for reporting to the charge nurse?

Correct Answer: C

Rationale: The correct answer is C: Sunken fontanels. This finding indicates dehydration in the infant, which can be a serious complication requiring immediate intervention. Dehydration can lead to further elevation of bilirubin levels and potential neurological complications. Reporting this to the charge nurse is crucial for prompt assessment and intervention. Incorrect choices: A: Conjunctivitis - Although important, it is not a priority over a sign of dehydration. B: Bronze skin discoloration - This may be a common side effect of phototherapy and does not indicate an urgent issue. D: Maculopapular skin rash - While it should be monitored, it does not take precedence over a sign of dehydration.

Question 2 of 5

A nurse is assisting with an in-service for newly licensed nurses about neonatal abstinence syndrome in newborns. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?

Correct Answer: B

Rationale: The correct answer is B: The newborn will have a continuous high-pitched cry. This is indicative of neonatal abstinence syndrome (NAS) due to maternal substance use during pregnancy. The high-pitched cry is a common symptom of NAS, reflecting the newborn's central nervous system irritability. The other choices are incorrect because decreased muscle tone (Choice A) is not a typical symptom of NAS, newborns with NAS tend to have increased muscle tone; sleeping for 2 to 3 hours after a feeding (Choice C) is a normal newborn behavior and not specific to NAS; mild tremors when disturbed (Choice D) may occur but are not as characteristic of NAS as the high-pitched cry.

Question 3 of 5

A nurse concludes that the parent of a newborn is not showing positive indications of parent-infant bonding. The parent appears very anxious and nervous when asked to bring the newborn to the other parent. Which of the following actions should the nurse use to promote parent-infant bonding?

Correct Answer: D

Rationale: The correct answer is D because providing reinforcement about infant care when the parent is present can help build the parent's confidence and competence in caring for the newborn, which can enhance parent-infant bonding. By offering support and guidance during interactions with the newborn, the parent can feel more comfortable and connected to the baby. A: Handing the parent the newborn and suggesting they change the diaper may increase their anxiety and not address the underlying issue of bonding. B: Asking the parent why they are anxious and nervous is important but may not directly promote bonding without providing concrete support. C: Telling the parent they will grow accustomed to the newborn does not actively support bonding or address the parent's current concerns. In summary, choice D is the best option as it provides practical assistance and positive reinforcement to help the parent feel more confident in caring for the newborn, ultimately fostering parent-infant bonding.

Question 4 of 5

A client who is 2 days postpartum reports that their 4-year-old son, who was previously toilet trained, is now wetting himself frequently. Which of the following statements should the nurse provide to the client?

Correct Answer: B

Rationale: The correct answer is B: Your son is displaying an adverse sibling response. This is the correct answer because the 4-year-old's regression in toilet training is likely a response to the recent birth of a new sibling. This behavior is common as the older child may feel jealous or neglected, leading to regression. Providing this statement will help the client understand the underlying cause of the behavior and address it appropriately. Incorrect choices: A: This choice suggests the child was not ready for toilet training, which is not the primary issue here. C: Counseling may be beneficial in some cases but is not the first-line intervention for this situation. D: Enrolling in preschool may not directly address the underlying cause of the behavior, which is related to the new sibling.

Question 5 of 5

A client in the delivery room just delivered a newborn, and the nurse is planning to promote parent-infant bonding. What should the nurse prioritize?

Correct Answer: D

Rationale: The correct answer is D: Position the newborn skin-to-skin on the client's chest. This promotes bonding through touch, warmth, and smell, stimulating the release of oxytocin in both the parent and the infant. Skin-to-skin contact enhances attachment, regulates the newborn's temperature and breathing, and supports breastfeeding initiation. A: Encouraging parents to touch and explore the newborn's features is important but not as crucial as immediate skin-to-skin contact for bonding and physiological benefits. B: Limiting noise and interruptions can create a calm environment but does not directly promote bonding like skin-to-skin contact. C: Placing the newborn at the client's breast is beneficial for breastfeeding initiation but may not provide the same level of closeness and comfort as skin-to-skin contact.

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