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. 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 client who is postpartum has a slightly boggy and displaced fundus to the right. Which of the following actions should the nurse take based on these findings?
- A. Encourage the client to perform Kegel exercises.
- B. Encourage the client to move to the left lateral position.
- C. Ask the client to rate her pain.
- D. Assist the client to the bathroom to void.
Correct answer: D
Rationale: A displaced and boggy fundus in a postpartum client typically indicates a full bladder, which can impede uterine contractions and increase the risk of postpartum hemorrhage. Assisting the client to the bathroom to void helps ensure the bladder is empty, aiding the fundus to contract and reducing the risk of complications. Encouraging Kegel exercises, changing positions, or assessing pain would not directly address the issue of the boggy fundus caused by a full bladder.
5. 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.
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