LPN LPN
ATI Maternal Newborn
1. When reinforcing teaching with new parents on bathing a newborn, a nurse observes a bluish-brown marking across the newborn's lower back. Which of the following statements should the nurse make concerning the variation?
- A. This is more commonly seen in newborns who have dark skin.
- B. This is a finding indicating hyperbilirubinemia.
- C. This is a forceps mark from an operative delivery.
- D. This is related to prolonged birth or trauma during delivery.
Correct answer: A
Rationale: A bluish-brown marking across the lower back is more commonly seen in newborns with dark skin. These markings are known as Mongolian spots and are benign. They are not related to hyperbilirubinemia, forceps marks, or trauma during delivery. Choice B is incorrect because hyperbilirubinemia presents as jaundice, not as a bluish-brown marking. Choice C is incorrect because forceps marks would have a different appearance and location. Choice D is incorrect as Mongolian spots are not related to prolonged birth or trauma during delivery.
2. 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?
- A. Conjunctivitis
- B. Bronze skin discoloration
- C. Sunken fontanels
- D. Maculopapular skin rash
Correct answer: C
Rationale: Sunken fontanels should be prioritized for reporting as they indicate dehydration, which is a critical concern in infants undergoing phototherapy. Dehydration can lead to serious complications, making it essential for the nurse to promptly inform the charge nurse for appropriate intervention and management. Conjunctivitis, bronze skin discoloration, and maculopapular skin rash are important findings to note, but in this scenario, sunken fontanels take precedence due to the potential severity of dehydration in infants.
3. A client who is pregnant and has phenylketonuria (PKU) is receiving teaching from a nurse. Which of the following foods should the nurse instruct the client to eliminate from her diet?
- A. Peanut butter
- B. Potatoes
- C. Apple juice
- D. Broccoli
Correct answer: A
Rationale: Individuals with phenylketonuria (PKU) have difficulty breaking down phenylalanine, an amino acid found in protein-rich foods like peanut butter. Therefore, clients with PKU should avoid foods high in phenylalanine, such as peanut butter, to prevent adverse effects on their health. Choices B, C, and D are not typically high in phenylalanine and do not pose the same risk to individuals with PKU as peanut butter.
4. 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.
5. When checking for the Moro reflex in a newborn, what action should the nurse take?
- A. Hold the newborn vertically under arms and allow one foot to touch the table.
- B. Stimulate the pads of the newborn's hands with stroking or massage.
- C. Stimulate the soles of the newborn's feet on the outer lateral surface of each foot.
- D. Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward.
Correct answer: D
Rationale: The correct action to check for the Moro reflex in a newborn is to hold the newborn in a semi-sitting position and then allow the newborn's head and trunk to fall backward. The Moro reflex is elicited by a sudden loss of support or a loud noise. The normal response involves symmetrical abduction and extension of the arms, followed by their return to the midline in an embracing motion. Choices A, B, and C do not describe the correct method for assessing the Moro reflex and are therefore incorrect.
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