ATI Skills Module 3.0: Maternal Newborn
A nurse is assessing a new child who changed into born 2 days ago. Which of the following
findings must the nurse record to the provider?
Blackening of the stump of the umbilical twine
Redness of the pores and skin at the base of the umbilical cord stump
Scant quantity of dried blood at the skin across the umbilical twine stump
Hardening of the umbilical cord stump - ANS-Redness of the pores and skin at the bottom of
the umbilical wire stump.
Rationale: Redness of the pores and skin at the bottom of the umbilical twine is a sign of
infection that calls for further assessment. Therefore, the nurse need to file this locating to
the issuer. Other manifestations of contamination encompass: swelling, purulent drainage,
and a foul odor.
A nurse is assessing the fundal top for a client who's at 28 weeks of gestation. The nurse
ought to degree the distance in centimters between which two anatomicall landmarks?
The mons pubis and the xiphoid method
The top of the fundus and the umbilicus
The symphysis pubis and the top of the fundus
The mons pubis and the umbilicius - ANS-The symphysis and the top of the fundus
Rationale: The nurse should degree the peak of the purchaser's fundus among the higher
border of the symphis pubis and the pinnacle of the fundus. This measurement, in
centimeters, must correspond with the week of gestation the client is at while they're among
the 18th and thirtieth week of pregnancy, plus or minus 2 cm.
A nurse is assigning a 1-minute Apgar score to a newborn who's crying loudly. The new child
has a coronary heart charge of a hundred and forty/min, has well flexed arms and legs,
grimaces whilst the nurse rubs the soles in their feet, and is purple with mild acrocynosis.
What Apgar rating should the nurse assign to this newborn? - ANS-8
Rationale: Apgar scoring is an evaluation of 5 indicators of a newborn's physiologic kingdom:
coronary heart fee, respiration effort, muscle tone, reflex irritability, and coloration at 1 and
five min following delivery.
•For heart price: 0 manner absent, 1 is slow (beneath 100/min) and a couple of method
above 100/min. This newborn rankings a 2 for a coronary heart charge of one hundred
forty/min.
•For respiratory effort: 0 means absent, 1 approach sluggish or vulnerable and a pair of
reflects a noisy cry. This newborn rankings a 2 for crying loudly at shipping.
•For muscle tone: zero is flaccid, 1 indicates a few flexion of the extremities, and 2 is
properly-flexed. This newborn rankings a 2 for nicely-flexed extremities.
A nurse is assessing a new child who changed into born 2 days ago. Which of the following
findings must the nurse record to the provider?
Blackening of the stump of the umbilical twine
Redness of the pores and skin at the base of the umbilical cord stump
Scant quantity of dried blood at the skin across the umbilical twine stump
Hardening of the umbilical cord stump - ANS-Redness of the pores and skin at the bottom of
the umbilical wire stump.
Rationale: Redness of the pores and skin at the bottom of the umbilical twine is a sign of
infection that calls for further assessment. Therefore, the nurse need to file this locating to
the issuer. Other manifestations of contamination encompass: swelling, purulent drainage,
and a foul odor.
A nurse is assessing the fundal top for a client who's at 28 weeks of gestation. The nurse
ought to degree the distance in centimters between which two anatomicall landmarks?
The mons pubis and the xiphoid method
The top of the fundus and the umbilicus
The symphysis pubis and the top of the fundus
The mons pubis and the umbilicius - ANS-The symphysis and the top of the fundus
Rationale: The nurse should degree the peak of the purchaser's fundus among the higher
border of the symphis pubis and the pinnacle of the fundus. This measurement, in
centimeters, must correspond with the week of gestation the client is at while they're among
the 18th and thirtieth week of pregnancy, plus or minus 2 cm.
A nurse is assigning a 1-minute Apgar score to a newborn who's crying loudly. The new child
has a coronary heart charge of a hundred and forty/min, has well flexed arms and legs,
grimaces whilst the nurse rubs the soles in their feet, and is purple with mild acrocynosis.
What Apgar rating should the nurse assign to this newborn? - ANS-8
Rationale: Apgar scoring is an evaluation of 5 indicators of a newborn's physiologic kingdom:
coronary heart fee, respiration effort, muscle tone, reflex irritability, and coloration at 1 and
five min following delivery.
•For heart price: 0 manner absent, 1 is slow (beneath 100/min) and a couple of method
above 100/min. This newborn rankings a 2 for a coronary heart charge of one hundred
forty/min.
•For respiratory effort: 0 means absent, 1 approach sluggish or vulnerable and a pair of
reflects a noisy cry. This newborn rankings a 2 for crying loudly at shipping.
•For muscle tone: zero is flaccid, 1 indicates a few flexion of the extremities, and 2 is
properly-flexed. This newborn rankings a 2 for nicely-flexed extremities.
