a nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia which of the following actions should the nurse take
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ATI LPN

Maternal Newborn ATI Proctored Exam 2023

1. While caring for a newborn undergoing phototherapy to treat hyperbilirubinemia, which of the following actions should the nurse take?

Correct answer: A

Rationale: It is crucial to cover the newborn's eyes with an opaque eye mask to prevent damage to the retinas and corneas from the phototherapy light. The eyes are particularly sensitive to the light used in phototherapy, and shielding them helps protect the newborn's delicate eyes from potential harm. Choice B is incorrect because the newborn should be undressed to maximize skin exposure to the phototherapy light. Choice C is incorrect because lotions or oils can interfere with the effectiveness of phototherapy. Choice D is incorrect because the newborn should be kept as still as possible to maximize exposure to the light.

2. A client at 11 weeks of gestation reports slight occasional vaginal bleeding over the past 2 weeks. After an examination, the provider informs the client that the fetus has died, and the placenta, fetus, and tissues remain in the uterus. How should the nurse document these findings?

Correct answer: B

Rationale: The correct answer is B: 'Missed miscarriage.' In a missed miscarriage, fetal and placental tissues are retained in the uterus after fetal demise, which matches the scenario described in the question. This situation often requires medical or surgical intervention to remove the remaining products of conception and prevent complications. 'Incomplete miscarriage' (Choice A) typically involves partial expulsion of products of conception, 'Inevitable miscarriage' (Choice C) indicates that miscarriage is in progress and cannot be stopped, and 'Complete miscarriage' (Choice D) signifies that all products of conception have been expelled from the uterus.

3. A pregnant client is learning about Kegel exercises in the third trimester. Which statement signifies understanding of the teaching?

Correct answer: B

Rationale: Kegel exercises are beneficial during pregnancy to help strengthen pelvic muscles, which is crucial for childbirth. Pelvic muscle stretching during birth is a key aspect of labor, making choice B the correct statement indicating understanding of the teaching. Choices A, C, and D are incorrect because Kegel exercises primarily focus on strengthening pelvic floor muscles to support the uterus, bladder, and bowel, aiding in labor and delivery. They are not directly related to preventing constipation, decreasing backaches, or preventing stretch marks.

4. A healthcare professional is assessing a late preterm newborn. Which of the following clinical manifestations is an indication of hypoglycemia?

Correct answer: D

Rationale: The correct answer is D, respiratory distress, as it is a clinical manifestation of hypoglycemia in newborns. Other signs of hypoglycemia include an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures. Hypertonia, increased feeding, and hyperthermia are not typically associated with hypoglycemia in newborns. Hypertonia is more indicative of neurological issues, increased feeding is not a common sign of hypoglycemia, and hyperthermia is not a typical symptom of low blood sugar.

5. A nurse is assisting the nurse manager with an educational session about ways to prevent TORCH infections during pregnancy with a group of newly licensed nurses. Which of the following statements by one of the session participants indicates understanding?

Correct answer: D

Rationale: The correct answer is D. To prevent TORCH infections during pregnancy, it is essential for clients to avoid consuming undercooked meat, as it can be a potential source of toxoplasmosis. This infection, along with others in the TORCH group, can pose risks to the fetus, making it crucial for pregnant individuals to follow proper food safety practices. Choices A, B, and C are incorrect because seeking an immunization against rubella, receiving prophylactic treatment for cytomegalovirus, and avoiding crowded places are not directly related to preventing TORCH infections through food safety measures.

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