Maternal Newborn Skills ATI

A newborn delivered vaginally at term 1 min ago cried loudly at delivery, has a heart rate of 140/min, has well flexed arms and legs, grimaces when the nurse rubs the soles of his feet, and is pink with mild acrocyanosis. What Apgar score should the nurse assign to this newborn?

8

You obtain a blood specimen from the newborn and return him to his mother's room. You assure her that you will let her know when the provider sees the result. An hour later, you obtain the result - 14.6 mg/dL. You explain what you're doing as you prepare the infant for phototherapy, but the mother has questions. She acknowledges that you said you need to protect her baby's eyes from the light, but she tells you she's concerned that the ultraviolet rays will burn her baby's skin. Which of the following is an appropriate response? A."Phototherapy lights emit very little ultraviolet radiation, not even enough to redden your baby's skin." B."The incubator I'm putting him in acts like a shield to protect him from radiation." C."We're going to watch him closely and apply baby lotion to protect his skin."

A."Phototherapy lights emit very little ultraviolet radiation, not even enough to redden your baby's skin.

Your patient has just breastfed her infant and changes his diaper. She shares her concerns with you. Which of the following is an appropriate response? A."This is a good sign. These changes show that his bilirubin is breaking down and leaving his body." B."This could indicate that he's becoming dehydrated. Let's try feeding him more often." C."That's because you are breastfeeding. We expect breast milk to cause these changes."

A."This is a good sign. These changes show that his bilirubin is breaking down and leaving his body."

A nurse is caring for a term newborn who has just has a circumcision using the Gomco clamp technique. Which of the following instructions should the nurse include when teaching the parents to care for the site? (SATA) Apply petroleum jelly to the penis for the first 24 hr. Cleanse the penis with warm water and mild soap. Apply gentle pressure from a sterile gauze pad to control slight bleeding. Gently wipe away any yellow exudate on the penis. Apply the diaper loosely over the penis.

Apply petroleum jelly to the penis for the first 24 hr. Apply gentle pressure from a sterile gauze pad to control slight bleeding. Apply the diaper loosely over the penis.

A nurse is assessing a patient who is 1 day postpartum and is not breastfeeding. The nurse notes the patient breast are engorged. Which of the following actions is appropriate for the nurse to take? Applying ice packs Wearing a loose-fitting bra Pumping her breasts Taking a warm shower

Applying ice packs

You perform Apgar scoring at 1 minute. The newborn cried loudly at delivery, has a heart rate of 148 beats/minute, has well flexed arms and legs, cries when you rub the soles of her feet, and is pink with mild acrocyanosis. Which Apgar score should you assign to this newborn? A.8 B.9 C.10

B. 9 Yes. This is the correct choice. For heart rate, you assign 2 because the newborn's heart rate is above 100 beats/minute. For respiratory effort, you assign 2 for a good cry. For muscle tone, you assign 2 for well-flexed extremities. For reflex irritability, you assign 2 for crying when you rub the soles of her feet. For color, you assign 1 for pink with mild acrocyanosis. Adding the scores of 2, 2, 2, 2, and 1, this newborn's Apgar score at 1 min is 9.

Phototherapy continues, and the newborn's bilirubin level decreases slightly. The patient and her newborn are now ready for discharge. Which of the following instructions should you give the patient? A."Expect the phototherapy blanket to keep your baby warm." B."Apply the eye mask after feedings." C."Be sure to feed your baby at least every 3 hours."

C."Be sure to feed your baby at least every 3 hours."

Which additional instructions should you reinforce with your patient at this time? SATA A."Let us know if there is an increase in the frequency of how often you are using the restroom and urinating." B."Report any increases in flatulence, belching, or constipation immediately." C."Call us right away if you do not feel your baby move at least four times per hour." D."Take your blood pressure while you are seated and support your arm at heart level." E."Report any dizziness or blurry vision immediately."

C."Call us right away if you do not feel your baby move at least four times per hour." D."Take your blood pressure while you are seated and support your arm at heart level." E."Report any dizziness or blurry vision immediately."

Your patient's answer to which of the following questions will give you the information you need to determine her estimated date of birth (EDB)? A."How many menstrual periods have you missed?" B."On what date did you first notice feeling nauseated in the morning?" C."What is the date of the first day of your last menstrual period?"

C."What is the date of the first day of your last menstrual period?"

A nurse is caring for a patient who is in labor and has pain in her lower back because the fetal head is in a posterior position. Which of the following nonpharmacological pain management techniques is likely to be most effective in relieving this type of pain? Counterpressure Effleurage Therapeutic touch Breathing techniques

Counterpressure

After determining that the newborn is breathing spontaneously and her body is pink, which of the following is your first assessment priority? A.Gestational assessment B.Physical assessment C.Axillary temperature D.Apgar scoring

D. Apgar Scoring

To minimize morning nausea, you recommend that the patient. A.drink plenty of clear fluids within 30 minutes of waking. B.avoid salty and tart foods when feeling nauseated. C.be sure to warm your food before eating it. D.eat dry, starchy foods first thing in the morning.

D.eat dry, starchy foods first thing in the morning.

A nurse is assessing a patient who is 20 weeks of gestation. She instructs the patient to be sure to report headaches, blurred vision, and swelling of her hands because these are indications of which of the following complications of pregnancy? Gestational diabetes Preeclampsia Hyperemesis gravidarum Abruptio placentae

Preeclampsia

A nurse is performing umbilical cord care for a term newborn. Which of the following findings requires further assessment and intervention? Blackening of the stump Redness at the base Clear gel at the tip Hardening of the stump

Redness at the base

A nurse is assessing a patient at a routine antepartum visit. For a rough estimate of the number of gestational weeks the patient is at, the nurse should measure the number of cm between which two anatomical landmarks? The mons pubis and the xiphoid process The top of the fundus and the umbilicus The symphysis pubis and the top of the fundus The mons pubis and the umbilicus

The symphysis pubis and the top of the fundus

A nurse is caring for a term newborn who has just had a circumcision using the Gomco clamp technique. Which of the following instructions should the nurse include when teaching the parents to care for the site? (Select all that apply.) Apply petroleum jelly to the penis for the first 24 hr. Cleanse the penis with warm water and mild soap. Apply gentle pressure from a sterile gauze pad to control slight bleeding. Gently wipe away any yellow exudate on the penis. Apply the diaper loosely over the penis.

-Apply petroleum jelly to the penis for the first 24 hr. -Apply gentle pressure from a sterile gauze pad to control slight bleeding. -Apply the diaper loosely over the penis.

Which of the following instructions should you give your patient at this time? A.Include about 60 to 70 grams of protein in her diet. B.Restrict fluids to about 40 oz per day. C.Limit sodium intake to less than 1 g per day.

A.Include about 60 to 70 grams of protein in her diet.

You keep the newborn under the radiant heat warmer until it is time to assign the 5-minute Apgar score. The newborn's hands and feet are now pink, and you assign a score of 10. Soon afterward, you notice some secretions bubbling out of the newborn's nose and mouth. Which of the following are appropriate actions for you to take? SATA A.Use a bulb syringe to suction the secretions. B.Percuss the newborn's chest to loosen secretions. C.Suction the secretions from the newborn's mouth first. D.Insert the tip of the suction apparatus into the center of the newborn's mouth. E.Use deep nasal suction with a suction catheter in the infant's nasopharyngeal passageway.

A.Use a bulb syringe to suction the secretions. C.Suction the secretions from the newborn's mouth first.

A nurse is assessing a patient who is 1 day postpartum and is not breastfeeding. The nurse notes the patients breasts are engorged. which of the following actions is appropriate for the patient to take? Applying ice packs Wearing a loose-fitting bra Pumping her breasts Taking a warm shower

Applying ice packs

Once you have placed the newborn in an incubator, applied the mask to his eyes, and covered the diaper area with a "string bikini" you've created from a surgical mask, you initiate phototherapy. Which of the following instructions should you give the patient about feeding her newborn during his phototherapy treatment? A."Phototherapy can cause dehydration, so we'll have to give him water between feedings." B."You can breastfeed your baby as usual. We'll take him out of the incubator, remove his mask, and wrap him as usual for feeding times." C."He'll have to have formula so we can measure his intake carefully. But you can pump your breasts to maintain your milk supply."

B."You can breastfeed your baby as usual. We'll take him out of the incubator, remove his mask, and wrap him as usual for feeding times."

Here's your challenge. You are working on mother-baby unit. You are caring for a patient who is 2 days postpartum following a primary cesarean delivery and is breastfeeding her newborn. The nursing assistant comes to tell you about her observations. You enter your patient's room and explain the situation. She appears quite concerned and asks you to explain what bilirubin is and what this means for her baby. Which of the following is an appropriate response to this patient at this time? A."Don't worry about it just yet. It's really routine at this point, and it's something that happens to a lot of newborns. We'll let you know if there is any cause for concern." B."You might have noticed a yellowish tinge to your baby's skin. This can develop from the breakdown of fetal blood cells he no longer needs. A blood test will tell us if the substance that results, called bilirubin, has reached levels that require treatment." C."Bilirubin builds up in a baby's blood for many reasons. It could mean a blood incompatibility or an infection, and really high levels can cause neurological problems."

B."You might have noticed a yellowish tinge to your baby's skin. This can develop from the breakdown of fetal blood cells he no longer needs. A blood test will tell us if the substance that results, called bilirubin, has reached levels that require treatment."

You explain that the method you will use is only an estimate, and that many factors could change when she will actually deliver. She says she understands, so you proceed to use Nägele's rule and tell her that her estimated "due date" is A.January 23. B.January 30. C.February 2.

B.January 30.

After the newborn opens her mouth, you should make sure that? A.the mother moves her breast forward into the newborn's mouth. B.the newborn's cheeks and chin touch the breast. C.the newborn's cheeks are dimpled during sucking.

B.the newborn's cheeks and chin touch the breast.

A nurse is teaching the parents of a term newborn how to bathe him. Which of the following instructions should the nurse include? Bathe him every day. Give him a bath after he has had a feeding. Give him a sponge bath until his cord stump falls off. Clean his ears and nose with cotton swabs.

Give him a sponge bath until his cord stump falls off.

The nurse is performing a gestational age assessment using the New Ballard Score for newborn maturity rating. Which of the following indicate that the newborn is premature? Flexion of the extremities at rest Creases over the entire plantar surface Leathery skin Flat areola

Flat areola

The nurse is performing a gestational age assessment using the New Ballard Score for newborn maturity rating. Which of the following indicate that the newborn is premature? Flexion of the extremities at rest Creases over the entire plantar surface Leathery skin Flat areola

Flat areola

A nurse is teaching the parents of a term newborn how to bathe him. Which of the following instructions should the nurse include? Bathe him every day. Give him a bath after he has had a feeding. Give him a sponge bath until his cord stump falls off. Clean his ears and nose with cotton swabs.

Give him a sponge bath until his cord stump falls off.

a nurse is assessing a patient who is at 20 weeks gestation. She instructs the patient to be sure to report headaches, blurred vision, and swelling of the hands because these are indications of which of the following complications of pregnancy? Gestational diabetes Preeclampsia Hyperemesis gravidarum Abruptio placentae

Preeclampsia

A patient who is 1 day postpartum tells the nurse that she is concerned about her newborn receiving enough nourishment from breastfeeding. The nurse should explain that she should look for which of the following as a sign of adequate nutrition? The newborn feeds at least six times in 24 hr. The newborn has six wet diapers and three stools per day after day 4. The milk supply is plentiful by the newborn's second day. The newborn has returned to his birth weight 6 to 8 days following delivery.

The newborn has six wet diapers and three stools per day after day 4.

A patient who is 1 day postpartum tells the nurse that she is concerned about her newborn receiving enough nourishment from the breastfeeding. The nurse should explain that she should look for which of the following as a sign of adequate nutrition? The newborn feeds at least six times in 24 hr. The newborn has six wet diapers and three stools per day after day 4. The milk supply is plentiful by the newborn's second day. The newborn has returned to his birth weight 6 to 8 days following delivery.

The newborn has six wet diapers and three stools per day after day 4.

A nurse is asssessing a patient at a routine antepartum visit. For a rough estimate of the number of gestational weeks the patient is at, the nurse should measure the number of cm between which two anatomical landmarks? The mons pubis and the xiphoid process The top of the fundus and the umbilicus The symphysis pubis and the top of the fundus The mons pubis and the umbilicus

The symphysis pubis and the top of the fundus

You clear the secretions from the newborn's mouth and nose, then proceed to perform eye prophylaxis, instilling the prescribed ophthalmic ointment to prevent eye inflammation. You also administer vitamin K intramuscularly to prevent hemorrhagic disease. Your patient wants to begin breastfeeding immediately, so you wrap the newborn in a warmed blanket, place a cap on her head, and place her in your patient's arms. Which of the following newborn reflexes will assist the newborn as her mother initiates breastfeeding? A.Moro B.Extrusion C.Rooting

c. Rooting