ATI RN
ATI Capstone Maternal Newborn Assessment Quizlet
1. A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Swaddle the newborn tightly
- B. Provide frequent tactile stimulation
- C. Position the newborn in a prone position
- D. Offer large feedings every 4 hours
Correct answer: A
Rationale: The correct action for the nurse to take when caring for a newborn with neonatal abstinence syndrome is to swaddle the newborn tightly. Swaddling helps to provide comfort and reduce irritability in these newborns. Choice B, providing frequent tactile stimulation, may exacerbate the symptoms of neonatal abstinence syndrome by overstimulating the newborn. Choice C, positioning the newborn in a prone position, is not recommended as it increases the risk of sudden infant death syndrome (SIDS). Choice D, offering large feedings every 4 hours, is not appropriate as newborns with neonatal abstinence syndrome may have feeding difficulties and need smaller, more frequent feedings.
2. A client in the first trimester of pregnancy who is experiencing nausea is receiving teaching from a nurse. Which of the following instructions should the nurse include in the teaching?
- A. Drink water with meals
- B. Consume small, frequent meals
- C. Eat high-fat foods
- D. Lie down after eating
Correct answer: B
Rationale: The correct instruction for a client in the first trimester of pregnancy experiencing nausea is to consume small, frequent meals. This helps alleviate nausea by preventing an empty stomach and maintaining stable blood sugar levels. Drinking water with meals can sometimes exacerbate nausea, especially in the case of morning sickness. Eating high-fat foods can be heavy on the stomach and worsen nausea. Lying down after eating can lead to reflux and is not recommended, especially for pregnant individuals experiencing nausea.
3. A client in the first stage of labor is experiencing lower back pain and asks the nurse what can be done to relieve the pain. Which of the following interventions should the nurse suggest?
- A. Perform effleurage on the client's abdomen
- B. Apply counterpressure to the client's sacrum
- C. Provide a back massage with lavender oil
- D. Administer opioid analgesics
Correct answer: B
Rationale: Applying counterpressure to the sacrum can help alleviate lower back pain during labor by reducing pressure on the nerves. Effleurage on the abdomen, back massage with lavender oil, and administering opioid analgesics are not specifically targeted at relieving lower back pain, making them less effective interventions in this scenario.
4. A healthcare provider is assessing a newborn who is 12 hours old. Which of the following findings should the provider report?
- A. Respiratory rate 50/min
- B. Blood glucose 30 mg/dL
- C. Blood pressure 60/40 mm Hg
- D. Heart rate 140/min
Correct answer: B
Rationale: A blood glucose level of 30 mg/dL in a newborn is significantly low and indicates hypoglycemia, which can be dangerous in a newborn. Hypoglycemia in a newborn can lead to neurological issues and requires immediate attention. The other findings provided, such as a respiratory rate of 50/min, blood pressure of 60/40 mm Hg, and a heart rate of 140/min, are within normal ranges for a newborn and do not require immediate reporting unless accompanied by clinical signs of distress.
5. A nurse is assessing a newborn who is 1 day old. Which of the following findings should the nurse report to the provider?
- A. Heart rate 160/min
- B. Axillary temperature 36.8°C (98.2°F)
- C. Yellow-tinged skin
- D. Respiratory rate 42/min
Correct answer: C
Rationale: The correct answer is C: Yellow-tinged skin. Yellow-tinged skin within the first 24 hours of life can indicate pathological jaundice and should be reported to the provider. High heart rate (Choice A), normal axillary temperature (Choice B), and slightly elevated respiratory rate (Choice D) are common findings in newborns and may not necessarily require immediate reporting unless they persist or are significantly abnormal.
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