Maternity ATI 12-14
A nurse is reinforcing teaching about bottle-feeding with a client who is postpartum. Which of the following statements by the client indicates a need for further teaching?
"Each feeding should last about 15 minutes."
A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother's room. Which of the following statements is an appropriate response by the nurse?
"Have the mother call and I will take the baby to the room."
A nurse is reinforcing teaching about formula feeding to a group of parents of newborns. Which of the following statements by one of the parents indicates a need for further teaching?
"I will ensure my baby's feedings last 10 to 15 minutes."
A nurse is reinforcing discharge teaching about circumcision with the parent of a newborn who had a circumcision using the Plastibell device. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)
"I'll expect the plastic ring to fall off by itself within a week" "I'll call the doctor if I see any bleeding" "I'll make sure his diaper is loose in the front"
A nurse is reinforcing teaching about phenylketonuria (PKU) testing with the parent of a newborn. Which of the following statements by the parent indicates a need for further teaching?
"My baby will be place under special lights if the test is elevated."
A client is concerned that her newborn has "crossed eyes." Which of the following statements is a therapeutic response by the nurse?
"Newborns lack the necessary muscle control to regulate eye movement."
A nurse is caring for a newborn who was delivered by vacuum extraction and has swelling on his head that crosses the suture line. The newborn's mother asks about the swelling on her newborn's head. Which of the following responses should the nurse make?
"This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor."
A nurse is collecting data from a newborn 1 hr after delivery. Which of the following respiratory rates is within the expected reference range for a newborn?
48/min
A nurse in the newborn nursery is receiving report on four newborns. Which of the following newborns should the nurse see first?
A newborn who is 12 hr old and has an axillary temperature of 37.8 C (100 F)
A nurse is preparing to administer oxygen to a newborn who was born at 30 weeks of gestation. Which of the following actions should the nurse take?
Administer warm, humidified oxygen to the newborn.
A nurse is reinforcing teaching with a new mother about the purpose of administering vitamin K to her newborn following delivery. The nurse should explain that the purpose of administering vitamin K is to prevent which of the following complications?
Bleeding
A nurse is caring for a newborn who is small for gestational age (SGA). Which of the following findings should the nurse expect?
Blood glucose instability
A nurse is collecting data from a newborn and notes a swollen area on the head that does not cross the suture line. The nurse should document this finding as which of the following?
Cephalhematoma
A nurse is assisting with the care of a newborn following a vaginal delivery. Which of the following actions should the nurse perform first?
Clear the respiratory tract.
A nurse is contributing to the plan of care for a preterm newborn. To help the newborn conserve energy, which of the following actions should the nurse recommend?
Cluster the newborn's care activities.
A nurse is caring for a newborn shortly after birth and places the newborn under a radiant warmer. Which of the following potential complications does this action help to prevent?
Cold stress
A nurse is collecting data from a newborn who is 12 hr old. His respiration rate is 44/min, shallow, with periods of apnea lasting up to 5 seconds. Which of the following actions should the nurse take?
Continue routine monitoring.
A nurse is preparing to examine a post-term newborn immediately following delivery. Which of the following findings should she expect to observe? (select all that apply.)
Cracked, peeling skin. Moro reflex
A nurse is collecting data from an infant who has hydrocephalus. Which of the following findings should the nurse expect?
Dilated scalp veins
A nurse is collecting data from a newborn and finds an apical pulse of 130/min. Which of the following actions should the nurse take?
Document this as an expected finding.
A nurse is caring for a newborn immediately following delivery. After assuring a patent airway, Which of the following actions should be the nurse's priority?
Dry the newborn.
A nurse is collecting data from a newborn immediately after delivery by a client who was at 42 weeks of gestation. Which of the following findings should the nurse expect?
Dry, cracked skin
A nurse is caring for a newborn immediately after birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?
Drying the newborn's skin thoroughly
A nurse is reinforcing teaching with a client about how to reduce the risk of giving birth to a newborn who has a neural tube defect. Which of the following instructions should the nurse include in the teaching?
Eat foods fortified with folic acid.
A nurse is updating the plan of care for a newborn who is undergoing phototherapy. Which of the following actions should the nurse include in the plan?
Encourage the newborn to breastfeed every 2 hr.
A nurse is collecting data from a newborn who is 48-hr old. Which of the following findings should the nurse report to the provider?
Generalized petechiae
A nurse is reinforcing teaching with the parents of a newborn about caring for the umbilical cord stump. Which of the following instructions should the nurse include?
Give the newborn a sponge bath until the cord stump falls off.
A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following treatments should the infant receive?
Hepatitis B immune globulin and the hepatitis B vaccine within 12 hr of birth
A nurse is collecting data from a newborn who weighs 5,160 g (11lb, 6 oz) and whose mother has diabetes mellitus. For which of the following data should the nurse monitor?
Hypoglycemia
A nurse is assisting in the care of a newborn shortly after birth. Which of the following actions should the nurse take to assist in the prevention of hyperbilirubinemia?
Initiate early feeding.
A nurse is caring for several newborn clients. For which of the following findings should the nurse notify the charge nurse?
Jaundice in an infant who is 4-hr old
A nurse is caring for a newborn who has a myelomeningocele and is admitted to the newborn intensive care unit (NICU) to await surgery. Which of the following nursing goals is priority in the care of this infant?
Maintain integrity of the sac.
A nurse is admitting a term newborn to the nursery following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following?
Maternal/newborn blood group incompatibility
A nurse is collecting data from a newborn. Which of the following anatomical landmarks should the nurse use to measure chest circumference?
Nipple line
A nurse who is caring for a newborn observes signs of respiratory distress, jitteriness, and lethargy. Which of the following actions should the nurse take?
Obtain blood glucose by heel stick.
A nurse is reinforcing teaching with a client who is pregnant and has phenylketonuria (PKU). Which of the following foods should the nurse instruct the client to eliminate from her diet?
Peanut Butter
A nurse is collecting data about reflexes from a newborn. Which of the following actions should the nurse take to elicit the newborn's Moro reflex?
Perform a sharp hand clap near the infant.
A nurse is assisting with the care of a newborn who has a myelomeningocele. Which of the following actions by the nurse is appropriate?
Place the newborn in a prone-kneeling position.
A nurse is reinforcing teaching with the mother of a newborn who is small for gestational age. Which of the following should the nurse include as a cause of this condition?
Placental insufficiency
A nurse is assisting in the plan of care for a client who is pregnant and has phenylketonuria (PKU). Which of the following actions should the nurse include in the plan of care?
Reinforce teaching about a protein-free diet.
A nurse is assisting with the care of a newborn immediately following a cesarean delivery. The nurse's highest priority is the monitor the newborn for which of the following?
Respiratory distress
A nurse is collecting data from a newborn who has respiratory distress syndrome and is experiencing respiratory acidosis. Which of the following risk factors predisposes the newborn to respiratory difficulties?
Small for gestational age
A nurse is assisting in the care of a newborn immediately following birth. The nurse notes mucus bubbling out of the newborn's mouth and nose. Which of the following actions should the nurse take first?
Suction the newborn's mouth with a bulb syringe.
A nurse is reinforcing teaching with a parent about using an iron fortified formula to feed her newborn. Which of the following information should the nurse include in the teaching?
The newborn's iron source will start to deplete.
A nurse is caring for a client who is breastfeeding and tells the nurse that she is concerned about her newborn's hydration. Which of the following nursing observations is appropriate to use in evaluating the adequacy of the newborn's hydration?
The number of wet diapers per day
A nurse is reinforcing teaching about umbilical cord care with a client who is postpartum. Which of the following instructions should the nurse include?
The stump should fall off in 10 to 14 days.
A nurse is caring for a newborn. How many blood vessels should the nurse expect to observe in the newborn's umbilical cord?
Two arteries and one vein
A nurse is preparing to administer vitamin K IM to a newborn. Into which of the following muscles should the nurse inject the medication?
Vastus lateralis
A nurse is reinforcing teaching about vitamin K with a client who is postpartum. Which of the following statements should the nurse include?
Vitamin K decreases the newborn's risk of hemorrhagic disorders.
A nurse is caring for a newborn who is small for gestational age. Which of the following findings is associated with this condition?
Wide skull sutures