LPN LPN
ATI Maternal Newborn
1. A healthcare provider is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn?
- A. 22/min
- B. 48/min
- C. 100/min
- D. 110/min
Correct answer: B
Rationale: The expected respiratory rate for a newborn is between 30 to 60 breaths per minute. A rate of 48 breaths per minute falls within this range, indicating normal respiratory function for a newborn. Choice A (22/min) is below the expected range, Choices C (100/min) and D (110/min) are above the expected range for a newborn's respiratory rate.
2. A client is receiving postpartum discharge teaching after being vaccinated for varicella due to lack of immunity. Which statement by the client indicates understanding?
- A. I will need a second vaccination at my postpartum visit.
- B. I need a second vaccination at my postpartum visit.
- C. I was given the vaccine to protect myself from varicella.
- D. I will be tested in 3 months to confirm my immunity status.
Correct answer: B
Rationale: The correct answer is B because the client needs a second varicella vaccination at the postpartum visit to ensure immunity. Option A is incorrect as it implies a future need for a second vaccination without a clear action plan. Option C is incorrect as the varicella vaccine is primarily for the client's protection, not others. Option D is not the appropriate action as waiting to be tested for immunity delays the necessary second vaccination.
3. When assisting a client with breastfeeding, which of the following reflexes will promote the newborn to latch?
- A. Babinski
- B. Rooting
- C. Moro
- D. Stepping
Correct answer: B
Rationale: The correct answer is B: Rooting. The rooting reflex is crucial in newborns as it helps them locate the nipple for feeding. This reflex involves turning the head towards a stimulus that touches the cheek or mouth, aiding in the process of latching onto the breast for breastfeeding. The Babinski reflex is the fanning out and curling of the toes when the sole of the foot is stroked, the Moro reflex is the startle reflex in response to a sudden noise or movement, and the stepping reflex is the appearance of taking steps when an infant is held upright with feet touching a solid surface. Therefore, choices A, C, and D are incorrect as they do not play a direct role in promoting a newborn to latch during breastfeeding.
4. 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?
- A. Your son may not have been ready for toilet training and should wear training pants.
- B. Your son is displaying an adverse sibling response.
- C. Your son may benefit from counseling.
- D. Consider enrolling your son in preschool to address the behavior.
Correct answer: B
Rationale: The regression in toilet training is a common adverse sibling response to the birth of a new baby. When a new sibling arrives, the older child may revert to behaviors from an earlier stage, such as bedwetting, to gain attention or cope with feelings of insecurity. This behavior is temporary and often resolves with time and reassurance. Recommending counseling or preschool at this point would be premature and not addressing the underlying cause of the behavior.
5. A client who is postpartum and has thrombophlebitis requires nursing interventions. Which of the following nursing interventions should the nurse recommend?
- A. Apply cold compresses to the affected extremity
- B. Massage the affected extremity
- C. Allow the client to ambulate
- D. Measure leg circumferences
Correct answer: D
Rationale: Measuring leg circumferences is crucial in monitoring for changes that may indicate worsening of thrombophlebitis, such as increased swelling or redness. This assessment helps in early detection of complications and timely intervention, reducing the risk of further health problems for the client. Applying cold compresses may worsen the condition by causing vasoconstriction. Massaging the affected extremity can dislodge a clot and lead to embolism. Allowing the client to ambulate may increase the risk of clot migration.
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