Question

A nurse is reviewing the facility protocol about newborn identification and safety with a new parent. Which of the following information should the nurse include?

Answer 1

Correct Answers:

You should check the identity of individuals who come to remove your baby from the room.

Rationale :

🟢 Parental involvement in newborn identification is essential for infant safety.

🟢 Verifying the identity of anyone removing the newborn helps prevent abduction.

🟢 This approach is supported by national hospital safety guidelines.

🟢 Encourages active parental vigilance.

🟢 Reduces risks of unauthorized removal of the infant.

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Answer 2

Correct Answers:

A client who has a positive pregnancy test.

Rationale :

🔴 Intrauterine devices (IUDs) are absolutely contraindicated in pregnancy due to risk of miscarriage or infection.

🔴 Inserting an IUD into a pregnant client can cause harm to the fetus.

🔴 Pregnancy must always be ruled out before IUD placement.

🔴 Other choices are not absolute contraindications.

🔴 Patient safety is prioritized by avoiding IUD in pregnancy.

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Answer 3

Correct Answers:

Sedation.

Rationale :

🟡 Sedation is a common adverse effect of nalbuphine hydrochloride (an opioid agonist-antagonist).

🟡 Opioids often cause CNS depression in laboring clients.

🟡 Monitor for decreased alertness or respiratory rate.

🟡 Sedation may affect both mother and newborn.

🟡 Be prepared to implement safety measures if sedation occurs.

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Answer 4

Correct Answers:

Fetal heart tones 98/min.

Rationale :

🟣 Fetal bradycardia (FHR <110 bpm) is an urgent sign of fetal compromise.

🟣 Takes priority over maternal fever or discharge due to immediate risk.

🟣 Low FHR may indicate cord prolapse or fetal hypoxia after rupture of membranes.

🟣 Requires immediate intervention to prevent fetal distress.

🟣 Always prioritize fetal life-threatening findings first.

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Answer 5

Correct Answers:

Temperature 38.4°C (101°F): Sign of potential worsening condition.

Rationale :

🟢 Fever postpartum can indicate infection or endometritis.

🟢 Higher than 38°C after the first 24 hours is concerning.

🟢 Requires evaluation and potential treatment.

🟢 Infection is a leading cause of postpartum complications.

🟢 Prompt reporting improves outcomes.

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Answer 6

Correct Answers:

Give a bolus of lactated Ringer's.

Rationale :

🔵 Epidural-induced hypotension is best treated with IV fluid bolus.

🔵 Restores circulating volume and stabilizes blood pressure.

🔵 Lateral position and fluids are first-line; meds if unresolved.

🔵 Prevents maternal and fetal hypoperfusion.

🔵 Other actions are not first-line for hypotension.

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Answer 7

Correct Answers:

Supine.

Rationale :

🟡 Supine (on the back) is the safest sleep position for newborns.

🟡 Reduces risk of sudden infant death syndrome (SIDS).

🟡 Endorsed by all pediatric safety organizations.

🟡 Avoid lateral or prone for sleep.

🟡 Reinforce during postpartum education.

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Answer 8

Correct Answers:

Image showing toes fanning out when the sole is stroked.

Rationale :

🔴 Positive Babinski reflex = toes fan out when the sole is stroked.

🔴 Indicates normal neurological function in newborns.

🔴 Should be present at birth and disappear by age 1.

🔴 Helps assess CNS development.

🔴 Other reflexes shown are grasp, rooting, stepping.

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Answer 9

Correct Answers:

Encourage the client to continue to breastfeed.

Rationale :

🟢 Continued breastfeeding helps resolve mastitis by emptying the breast.

🟢 Prevents milk stasis and further infection.

🟢 Relieves pain and promotes healing.

🟢 Stopping feeding can worsen the condition.

🟢 Most clients can breastfeed safely unless abscess forms.

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Answer 10

Correct Answers:

Reposition the newborn every 2 hours.

Rationale :

🟠 Frequent repositioning prevents pressure sores and skin breakdown during phototherapy.

🟠 Ensures even exposure to therapeutic light.

🟠 Improves bilirubin breakdown and excretion.

🟠 Standard protocol for phototherapy care.

🟠 Other options are not safe or effective.

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ATI PN Maternal Newborn-2023A

No.

1 :
A nurse is reviewing the facility protocol about newborn identification and safety with a new parent. Which of the following information should the nurse include?

2 :
A nurse in an obstetric clinic is caring for four clients .The nurse should identify that an intrauterine device is contraindicated for which of the following clients?

3 :
A nurse is assisting with the care of a client who is in labor and has received nalbuphine hydrochloride. Which of the following manifestations should the nurse identify as an adverse effect of this medication?

4 :
A nurse in a provider's office is collecting data from a client who is at 34 weeks of gestation and reports having a sudden gush of vaginal which of the following manifestations is the priority?

5 :
The nurse is collecting data from the client 24 hr later. How should the nurse interpret the findings?

6 :
A nurse is assisting with the care of a client who is in labor and has an epidural infusion for pain management. The client's blood pressure is 80/40 mm Hg. Which of the following actions should the nurse take?

7 :
A nurse is reinforcing discharge teaching about home safety with a client who is postpartum. In which of the following positions should the nurse instruct the client to place their newborn in the crib?

8 :
A nurse is collecting data from a newborn. The nurse should recognize that which of the following images demonstrates a positive Babinski reflex?

9 :
A nurse is contributing to the plan of care for a client who is postpartum and has mastitis. Which of the following actions should the nurse plan to take?

10 :
A nurse is contributing to the plan of care for a newborn who requires phototherapy for hyperbilirubinemia. Which of the following interventions should the nurse recommend including in the plan?

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ATI PN Maternal Newborn-2023A

No.

1 : A nurse is reviewing the facility protocol about newborn identification and safety with a new parent. Which of the following information should the nurse include?

2 : A nurse in an obstetric clinic is caring for four clients .The nurse should identify that an intrauterine device is contraindicated for which of the following clients?

3 : A nurse is assisting with the care of a client who is in labor and has received nalbuphine hydrochloride. Which of the following manifestations should the nurse identify as an adverse effect of this medication?

4 : A nurse in a provider's office is collecting data from a client who is at 34 weeks of gestation and reports having a sudden gush of vaginal which of the following manifestations is the priority?

5 : The nurse is collecting data from the client 24 hr later. How should the nurse interpret the findings?

6 : A nurse is assisting with the care of a client who is in labor and has an epidural infusion for pain management. The client's blood pressure is 80/40 mm Hg. Which of the following actions should the nurse take?

7 : A nurse is reinforcing discharge teaching about home safety with a client who is postpartum. In which of the following positions should the nurse instruct the client to place their newborn in the crib?

8 : A nurse is collecting data from a newborn. The nurse should recognize that which of the following images demonstrates a positive Babinski reflex?

9 : A nurse is contributing to the plan of care for a client who is postpartum and has mastitis. Which of the following actions should the nurse plan to take?

10 : A nurse is contributing to the plan of care for a newborn who requires phototherapy for hyperbilirubinemia. Which of the following interventions should the nurse recommend including in the plan?

1 :
A nurse is reviewing the facility protocol about newborn identification and safety with a new parent. Which of the following information should the nurse include?

2 :
A nurse in an obstetric clinic is caring for four clients .The nurse should identify that an intrauterine device is contraindicated for which of the following clients?

3 :
A nurse is assisting with the care of a client who is in labor and has received nalbuphine hydrochloride. Which of the following manifestations should the nurse identify as an adverse effect of this medication?

4 :
A nurse in a provider's office is collecting data from a client who is at 34 weeks of gestation and reports having a sudden gush of vaginal which of the following manifestations is the priority?

5 :
The nurse is collecting data from the client 24 hr later. How should the nurse interpret the findings?

6 :
A nurse is assisting with the care of a client who is in labor and has an epidural infusion for pain management. The client's blood pressure is 80/40 mm Hg. Which of the following actions should the nurse take?

7 :
A nurse is reinforcing discharge teaching about home safety with a client who is postpartum. In which of the following positions should the nurse instruct the client to place their newborn in the crib?

8 :
A nurse is collecting data from a newborn. The nurse should recognize that which of the following images demonstrates a positive Babinski reflex?

9 :
A nurse is contributing to the plan of care for a client who is postpartum and has mastitis. Which of the following actions should the nurse plan to take?

10 :
A nurse is contributing to the plan of care for a newborn who requires phototherapy for hyperbilirubinemia. Which of the following interventions should the nurse recommend including in the plan?