LPN LPN
ATI Maternal Newborn
1. 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.
2. A nurse is assisting with an in-service for newly licensed nurses about neonatal abstinence syndrome in newborns. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?
- A. The newborn will have decreased muscle tone.
- B. The newborn will have a continuous high-pitched cry.
- C. The newborn will sleep for 2 to 3 hours after a feeding.
- D. The newborn will have mild tremors when disturbed.
Correct answer: B
Rationale: The correct answer is B. A continuous high-pitched cry is a characteristic sign of neonatal abstinence syndrome, indicating withdrawal from drugs. Choices A, C, and D are incorrect because decreased muscle tone, sleeping for 2 to 3 hours after a feeding, and mild tremors when disturbed are not specific indicators of neonatal abstinence syndrome.
3. 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.
4. 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.
5. When calculating the Apgar score of a newborn at 1 minute after delivery, which of the following findings would result in a score of 6?
- A. 4
- B. 5
- C. 6
- D. 7
Correct answer: C
Rationale: The Apgar score is calculated based on five parameters: heart rate, respiratory effort, muscle tone, reflex irritability, and color. In this case, the newborn's findings at 1 minute after delivery indicate a heart rate >100/min (2 points), slow, weak cry (1 point), some flexion of extremities (1 point), grimace in response to suctioning (1 point), and body pink with blue extremities (1 point). Adding these points together results in a total Apgar score of 6, reflecting the newborn's initial assessment for their overall well-being. Choice A (4) is too low based on the given findings, while Choice B (5) is also lower than the correct score of 6. Choice D (7) is too high as it would require additional findings to reach that score.
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