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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Nursing Elites

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 in active labor reports back pain while being examined by a nurse who finds her to be 8 cm dilated, 100% effaced, -2 station, and in the occiput posterior position. What action should the nurse take?

Correct answer: C

Rationale: The nurse should assist the client into the hands and knees position during contractions to help relieve her back pain and facilitate the rotation of the fetus from the posterior to an anterior occiput position. This position can aid in optimal fetal positioning for delivery. Choice A, performing effleurage, is a massage technique that may provide comfort but does not address the fetal position. Placing the client in lithotomy position (Choice B) may not be ideal for a client experiencing back pain due to the occiput posterior position. Applying a scalp electrode to the fetus (Choice D) is not indicated solely for addressing the client's back pain.

3. A client who is at 40 weeks gestation and in active labor has 6 cm of cervical dilation and 100% cervical effacement. The client's blood pressure reading is 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?

Correct answer: D

Rationale: Turning the client onto her side is the appropriate nursing intervention in this scenario. This position can help improve blood pressure by enhancing venous return, which may aid in increasing perfusion to vital organs. It can also alleviate pressure on the inferior vena cava, promoting better circulation and supporting blood pressure stabilization during labor. Choices A, B, and C are incorrect. A cesarean birth is not indicated based on the information provided. Assisting the client to an upright position may worsen her blood pressure due to decreased venous return. Lastly, there is no indication for an immediate vaginal delivery solely based on the client's blood pressure reading.

4. A healthcare professional is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the professional use to help minimize the pain of the procedure for the newborn?

Correct answer: D

Rationale: Placing the newborn skin-to-skin on the mother's chest is an effective technique to significantly decrease the newborn's pain level and anxiety during a heel stick procedure. This approach provides comfort, warmth, and familiarity to the newborn, promoting a sense of security and reducing distress. It is important for the healthcare professional to implement this technique before, during, and after the procedure to optimize pain management and support newborn well-being. The other options, such as applying a cool pack, requesting an IM analgesic prescription, and using a manual lancet, are not appropriate for minimizing pain in a newborn during a heel stick procedure. Applying a cool pack may cause vasoconstriction and increase pain, requesting an IM analgesic for a routine heel stick is excessive, and using a manual lancet without additional comforting measures may not adequately address the newborn's pain and anxiety.

5. When discussing intermittent fetal heart monitoring with a newly licensed nurse, which statement should a nurse include?

Correct answer: C

Rationale: When discussing intermittent fetal heart monitoring, it is crucial to count the fetal heart rate after a contraction to determine baseline changes. This practice allows for the assessment of variations in the fetal heart rate pattern associated with uterine contractions. Monitoring the fetal heart rate after contractions provides valuable insights into fetal well-being and potential distress. Option A is incorrect because determining the baseline involves assessing the fetal heart rate over a more extended period. Option B is incorrect as auscultation every 5 minutes during the active phase of the first stage of labor is too frequent for intermittent monitoring. Option D is incorrect as auscultating the fetal heart rate every 30 minutes during the second stage of labor is too infrequent for proper monitoring of fetal well-being.

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