ATI Skills Module 3.0: Maternal Newborn
A nurse is assessing a newborn who was born 2 days ago. Which of the following findings
should the nurse report to the provider?
Blackening of the stump of the umbilical cord
Redness of the skin at the base of the umbilical cord stump
Scant amount of dried blood on the skin around the umbilical cord stump
Hardening of the umbilical cord stump - ANS-Redness of the skin at the base of the umbilical
cord stump.
Rationale: Redness of the skin at the base of the umbilical cord is an indication of infection that
requires further assessment. Therefore, the nurse should report this finding to the provider.
Other manifestations of infection include: swelling, purulent drainage, and a foul odor.
\A nurse is assessing the fundal height for a client who is at 28 weeks of gestation. The nurse
should measure the distance in centimters between which two anatomicall landmarks?
the mons pubis and the xiphoid process
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 measure the height of the client's fundus between the upper border
of the symphis pubis and the top of the fundus. This measurement, in centimeters, should
correspond with the week of gestation the client is at when they are between the 18th and 30th
week of pregnancy, plus or minus 2 cm.
\A nurse is assigning a 1-minute Apgar score to a newborn who is crying loudly. The newborn
has a heart rate of 140/min, has well flexed arms and legs, grimaces when the nurse rubs the
soles of their feet, and is pink with mild acrocynosis. What Apgar score should the nurse assign
to this newborn? - ANS-8
Rationale: Apgar scoring is an assessment of five indications of a newborn's physiologic state:
heart rate, respiratory effort, muscle tone, reflex irritability, and color at 1 and 5 min following
birth.
•For heart rate: 0 means absent, 1 is slow (below 100/min) and 2 means above 100/min. This
newborn scores a 2 for a heart rate of 140/min.
•For respiratory effort: 0 means absent, 1 means slow or weak and 2 reflects a loud cry. This
newborn scores a 2 for crying loudly at delivery.
•For muscle tone: 0 is flaccid, 1 indicates some flexion of the extremities, and 2 is well-flexed.
This newborn scores a 2 for well-flexed extremities.
A nurse is assessing a newborn who was born 2 days ago. Which of the following findings
should the nurse report to the provider?
Blackening of the stump of the umbilical cord
Redness of the skin at the base of the umbilical cord stump
Scant amount of dried blood on the skin around the umbilical cord stump
Hardening of the umbilical cord stump - ANS-Redness of the skin at the base of the umbilical
cord stump.
Rationale: Redness of the skin at the base of the umbilical cord is an indication of infection that
requires further assessment. Therefore, the nurse should report this finding to the provider.
Other manifestations of infection include: swelling, purulent drainage, and a foul odor.
\A nurse is assessing the fundal height for a client who is at 28 weeks of gestation. The nurse
should measure the distance in centimters between which two anatomicall landmarks?
the mons pubis and the xiphoid process
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 measure the height of the client's fundus between the upper border
of the symphis pubis and the top of the fundus. This measurement, in centimeters, should
correspond with the week of gestation the client is at when they are between the 18th and 30th
week of pregnancy, plus or minus 2 cm.
\A nurse is assigning a 1-minute Apgar score to a newborn who is crying loudly. The newborn
has a heart rate of 140/min, has well flexed arms and legs, grimaces when the nurse rubs the
soles of their feet, and is pink with mild acrocynosis. What Apgar score should the nurse assign
to this newborn? - ANS-8
Rationale: Apgar scoring is an assessment of five indications of a newborn's physiologic state:
heart rate, respiratory effort, muscle tone, reflex irritability, and color at 1 and 5 min following
birth.
•For heart rate: 0 means absent, 1 is slow (below 100/min) and 2 means above 100/min. This
newborn scores a 2 for a heart rate of 140/min.
•For respiratory effort: 0 means absent, 1 means slow or weak and 2 reflects a loud cry. This
newborn scores a 2 for crying loudly at delivery.
•For muscle tone: 0 is flaccid, 1 indicates some flexion of the extremities, and 2 is well-flexed.
This newborn scores a 2 for well-flexed extremities.
