ATI Maternal Newborn Test 5 Exam Study Guide

1. A nurse is caring for a client who is at 42 weeks gestation and in labor. The client asks the nurse what to expect because the baby is postmature. Which of the following statements should the nurse make? A. “Your baby will have excess body fat.” B. “Your baby will have flat areola without breast buds.” C. “Your baby’s heels will easily move to his ears.” D. “Your baby’s skin will have a leathery appearance.” Rationale: A. Excess body fat is seen in a newborn who is macrosomic. B. Flat areolas without breast buds are seen in a newborn who is preterm. C. Heels that are movable fully to the ears are seen in a newborn who is preterm. D. CORRECT: Leathery, cracked, and wrinkled skin is seen in a newborn who is postmature due to placental insufficiency. 2. A nurse is caring for an infant who has a high bilirubin level and is receiving phototherapy. Which of the following is the priority finding in the newborn? A. Conjunctivitis B. Bronze skin discoloration C. Sunken fontanels D. Maculopapular skin rash Rationale: A. Conjunctivitis is an important finding, but it is not the priority. B. Bronze skin discoloration is an important finding, but it is not the priority. C. CORRECT: Using the safety and risk reduction framework, sunken fontanels is the priority finding. Infants receiving phototherapy are at risk for dehydration from loose stools due to increased bilirubin excretion. D. Maculopapular skin rash is an important finding, but it is not the priority. 3. A nurse is called to the birthing room to assist with the assessment of a newborn who was born at 32 weeks of gestation. The newborn’s birth weight is 1,100 g. Which of the following are expected findings in this newborn? (Select all that apply.) A. Lanugo B. Long nails C. Weak grasp reflex D. Translucent skin E. Plump face Rationale: A. CORRECT: Characteristics of a preterm newborn include the presence of abundant lanugo. B. Long nails are a finding in a newborn who is postmature. C. CORRECT: A weak grasp reflex is characteristic of a preterm newborn. D. CORRECT: Skin that is thin, smooth, shiny, and translucent is a finding in a preterm newborn. E. A plump face would be observed in a newborn who is macrosomic. 4. A nurse is caring for a newborn who is preterm and has respiratory distress syndrome. Which of the following should the nurse monitor to evaluate the newborn’s condition following administration of synthetic surfactant? A. Oxygen saturation B. Body temperature C. Serum bilirubin D. Heart rate Rationale: A. CORRECT: Surfactant stabilizes the alveoli and helps increase oxygen saturation. B. Surfactant administration has no direct effect on body temperature. C. Surfactant administration has no direct effect on bilirubin levels. D. Surfactant administration has no direct effect on heart rate. 5. A nurse is teaching a newly licensed nurse about neonatal abstinence syndrome. Which of the following statements by the newly licensed nurse indicate understanding of the teaching? A. “The newborn will have decreased muscle tone.” B. “The newborn will have a continuous high‑pitched cry.” C. “The newborn will sleep for 2 to 3 hours after a feeding.” D. “The newborn will have mild tremors when disturbed.” Rationale: A. Increased muscle tone is seen in a newborn who has neonatal abstinence syndrome. B. CORRECT: A continuous high‑pitched cry is often an indication of CNS disturbances in a newborn who has neonatal abstinence syndrome. C. A newborn who has neonatal abstinence syndrome can have sleep pattern disturbances and would have difficulty sleeping for 2 to 3 hr after feeding. D. A newborn who has neonatal abstinence syndrome often has moderate to severe tremors when undisturbed. Most newborns exhibit mild tremors when disturbed.