LPN LPN
ATI Maternal Newborn
1. 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.
2. 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.
3. A client who is 2 days postpartum has a saturated perineal pad with bright red lochia containing small clots. What should the nurse document in the client's medical record?
- A. Moderate lochia rubra
- B. Excessive lochia serosa
- C. Light lochia rubra
- D. Scant lochia serosa
Correct answer: A
Rationale: The correct answer is 'Moderate lochia rubra.' On the second day postpartum, it is normal for lochia to be bright red and contain small clots, indicating moderate lochia rubra. This amount of bleeding is expected as the uterus continues to shed its lining after childbirth. Excessive lochia serosa, light lochia rubra, and scant lochia serosa do not accurately reflect the described scenario. Excessive lochia serosa is more characteristic of a later postpartum period, while light and scant lochia serosa are not consistent with the bright red color and small clots observed in this case.
4. A client in the delivery room just delivered a newborn, and the nurse is planning to promote parent-infant bonding. What should the nurse prioritize?
- A. Encourage the parents to touch and explore the newborn's features
- B. Limit noise and interruptions in the delivery room
- C. Place the newborn at the client's breast
- D. Position the newborn skin-to-skin on the client's chest
Correct answer: D
Rationale: Positioning the newborn skin-to-skin on the client's chest is the priority action to promote warmth, regulate the newborn's heart rate and breathing, and enhance parent-infant bonding. This method facilitates early bonding, stabilizes the baby's temperature, and encourages breastfeeding initiation. Encouraging parents to touch and explore the newborn's features is important but not the priority at this moment. Limiting noise and interruptions can be beneficial but not as crucial as skin-to-skin contact for bonding. Placing the newborn at the client's breast is essential for breastfeeding but should come after the initial skin-to-skin contact for bonding and temperature regulation.
5. 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.
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