ATI MATERNAL NEWBORN PROCTORED EXAM
Nursing Care of the Newborn and Family Study Guide
The nurse auscultates a neonate in resting position and hears a murmur. What further assessments
should the nurse make to know if the infant has any cardiac defects?
Measure the circumference of the
head. Assess movements of the lower
extremities.
Monitor blood pressure (BP) in upper extremities.
→ Assess blood pressure (BP) in all four extremities.
When murmurs are heard, the nurse should check the neonates’ BP from all four extremities to rule
out congenital heart diseases. Circumference of the head is measured to detect head-related
complications, such as microcephaly and hydrocephaly. However, it is unrelated to congenital heart
disease. Assessing the body movements would correlate more with the muscular activity of the
neonate, but not the cardiac activity.
Which interventions should the nurse perform to record the respiratory rate of a newborn 12 hours after
birth?
→ Count the rise and fall of the abdomen.
Count for 6 seconds and multiply by 10.
→ Observe for symmetry of chest movement.
→ Assess the infant’s respiratory rate.
Assess respiration after obtaining the temperature.
Respiration in a newborn is abdominal in nature and can be counted by observing or slightly feeling
the rise and fall of the abdomen. The nurse must observe for symmetry of chest movement and watch
for signs of respiratory distress or apnea. The respiratory rate varies with the state of alertness and
activity. It is preferable to observe the respiratory rate when the infant is asleep. Respiration should
be counted for one full minute to obtain an accurate count. There may be periods of apnea when
respiration can cease for about 20 seconds and resume again. The infant may cry and struggle while
the nurse determines the axillary temperature. This can affect the respiration rate. Hence, the nurse
must assess the respiratory rate before obtaining the temperature.
Newborns are at high risk for injury if appropriate safety precautions are not implemented. Parents
should be taught to do what?
Place the newborn on the abdomen (prone) after feeding and
for sleep. Avoid use of pacifiers.
→ Use a rear-facing car seat.
Use a crib with side rail slats that are no more than 3 inches apart.
The newborn should be in a rear-facing infant car safety seat from birth until 2 years of age or until
exceeding the car seat’s limits for height and weight. The prone position is no longer recommended
because it may interfere with chest expansion and lead to sudden infant death syndrome. Approved
pacifiers are safe to use and fulfill a newborn’s need to suck. If the newborn is breastfed, the use of
pacifiers should be delayed until breastfeeding is well established to avoid the development of nipple
confusion. Slats in a crib should be no more than 2 inches apart.
The nurse is providing information about caring for the infant at home after discharge. What teaching
by the nurse is appropriate if the infant has a "common cold?"
→ Hold the infant in an upright position when feeding.
Use a pillow to raise the head when sleeping.
Ensure the infant is fully dressed with warm
clothes. Ensure the infant receives frequent
large feedings.
The nurse must teach the parents to hold the infant in an upright position when feeding to relieve the
discomfort from accumulated secretions. The nurse must teach the parents to avoid use of a pillow to
raise the infant’s head. The head of the mattress must be elevated by 30 degrees to raise the infant’s
head and chest. The nurse must teach the parents not to overdress the infant, but to avoid drafts. The
infant must be fed frequently in small amounts to prevent overtiring.
p. 590
A client with a history of gonorrheal infection has just delivered a baby. What immediate intervention
should the nurse provide to the newborn to ensure safety?
Place the newborn in incubator.
→ Administer ophthalmic solution.
, Perform a heelstick puncture test.
Provide ventilator support to the
newborn.
The nurse should administer erythromycin ophthalmic solution to the newborn within 2 hours of birth to
prevent ophthalmia neonatorum caused by gonorrheal infection. Incubation is preferred when a
neonate has hypothermia in order to regulate the body temperature. Heelstick puncture is performed to
detect abnormalities in blood levels only if the neonate has any infection. Ventilator support is provided
if the neonate’s heart rate is below 100 beats/minute.
However, the heart rate is not decreased due to gonorrheal infection.
p. 568
, The nurse is using the CRIES pain scale to determine the pain level in a circumcised infant. What does
a score of 1 for "Sleeplessness" indicate?
The infant has been constantly
awake. The infant has been asleep
for an hour.
The infant has awakened only when touched.
→ The infant has awakened at frequent intervals.
If the infant has awakened at frequent intervals in the past hour, the "Sleeplessness" score is 1. The
score is 2 for the infant who has been constantly awake. The score is 0 for the infant who has been
asleep for an hour or sleeps well and awakens only when touched.
p. 584
Which statement provides helpful and accurate nursing advice concerning bathing
the newborn?
Newborns should be bathed every day, for the bonding as well as the cleaning.
→ Tub baths may be given before the infant’s umbilical cord falls off and the
umbilicus is healed.
Only plain warm water can be used to preserve the skin’s acid mantle.
→ Powders are not recommended because the infant can inhale powder.
Bathe immediately after feeding while baby is calm and relaxed.
Tub baths may be given as soon as an infant’s temperature has stabilized. Powder is not
recommended because of the risk of inhalation. If a parent chooses to use baby powder, it should
never be sprinkled directly onto the baby’s skin. The parent can apply a small amount of powder to
his or her own hand and then apply to the infant. Newborns do not need a bath every day, even if the
parents enjoy it. The diaper area and creases under the arms and neck need more attention.
Unscented mild soap is appropriate to use to wash the infant. Do not bathe immediately after a
feeding period because the increased handling may cause regurgitation.
Which interventions should the nurse perform to differentiate between cutaneous jaundice and normal
skin color in the newborn?
Blanch the skin with two fingers.
→ Apply pressure over the forehead.
Assess the skin color in bright light.
→ Use transcutaneous bilirubinometry.
→ Assess the color of the conjunctival sacs.
The nurse applies pressure with a finger over a bony area such as the forehead, nose, or sternum for
several seconds to empty all the capillaries in that spot. The blanched area will appear yellowish
before the capillaries refill if the newborn has jaundice. The nurse may use transcutaneous
bilirubinometry (TcB), which is a more accurate noninvasive assessment of hyperbilirubinemia. It
allows for repetitive estimations of bilirubin and works well on both dark and light-skinned infants. The
nurse assesses the conjunctival sacs and buccal mucosa of darker-skinned infants for yellow
coloration. While assessing the infant for birth trauma, the nurse differentiates hemorrhagic areas
from a skin rash or discolorations by blanching the skin with two fingers. This intervention does not
help in assessing the skin color. The nurse must assess the newborn in natural light because artificial
lighting and reflection from nursery walls can distort the actual skin color.
The nurse is performing a pulse oximetry test to assess a newborn for congenital heart defects. What
must the nurse bear in mind while performing this test?
The screening test is performed after 48 hours of age.
→ The test is performed in the newborn’s right hand and on one foot.
The infant has passed if oxygen saturation is greater than 80%.
The infant is evaluated in case of a 10% difference in the extremities.
The pulse oximetry test is a noninvasive screening test used to measure oxygen saturation. It is
performed in the right hand and on one foot of the newborn. Hypoxemia can be the first sign that a
congenital heart defect is present, so the test is performed at 24 to 48 hours of age. The infant
passes the test only if the oxygen saturation is greater than 95% in either extremity. There must be
no more than 3% difference between the upper and lower extremity readings. Immediate evaluation
is needed if the oxygen saturation is less than 90%.
p. 576
The nurse is caring for a full term infant immediately after birth. The infant is crying and has good
muscle tone. What interventions should the nurse perform for this infant?
→ Assess the airway and keep the neck slightly extended.
Wash the infant with warm water and wrap in a towel.
→ Assess the heart rate by grasping the base of the cord.
Nursing Care of the Newborn and Family Study Guide
The nurse auscultates a neonate in resting position and hears a murmur. What further assessments
should the nurse make to know if the infant has any cardiac defects?
Measure the circumference of the
head. Assess movements of the lower
extremities.
Monitor blood pressure (BP) in upper extremities.
→ Assess blood pressure (BP) in all four extremities.
When murmurs are heard, the nurse should check the neonates’ BP from all four extremities to rule
out congenital heart diseases. Circumference of the head is measured to detect head-related
complications, such as microcephaly and hydrocephaly. However, it is unrelated to congenital heart
disease. Assessing the body movements would correlate more with the muscular activity of the
neonate, but not the cardiac activity.
Which interventions should the nurse perform to record the respiratory rate of a newborn 12 hours after
birth?
→ Count the rise and fall of the abdomen.
Count for 6 seconds and multiply by 10.
→ Observe for symmetry of chest movement.
→ Assess the infant’s respiratory rate.
Assess respiration after obtaining the temperature.
Respiration in a newborn is abdominal in nature and can be counted by observing or slightly feeling
the rise and fall of the abdomen. The nurse must observe for symmetry of chest movement and watch
for signs of respiratory distress or apnea. The respiratory rate varies with the state of alertness and
activity. It is preferable to observe the respiratory rate when the infant is asleep. Respiration should
be counted for one full minute to obtain an accurate count. There may be periods of apnea when
respiration can cease for about 20 seconds and resume again. The infant may cry and struggle while
the nurse determines the axillary temperature. This can affect the respiration rate. Hence, the nurse
must assess the respiratory rate before obtaining the temperature.
Newborns are at high risk for injury if appropriate safety precautions are not implemented. Parents
should be taught to do what?
Place the newborn on the abdomen (prone) after feeding and
for sleep. Avoid use of pacifiers.
→ Use a rear-facing car seat.
Use a crib with side rail slats that are no more than 3 inches apart.
The newborn should be in a rear-facing infant car safety seat from birth until 2 years of age or until
exceeding the car seat’s limits for height and weight. The prone position is no longer recommended
because it may interfere with chest expansion and lead to sudden infant death syndrome. Approved
pacifiers are safe to use and fulfill a newborn’s need to suck. If the newborn is breastfed, the use of
pacifiers should be delayed until breastfeeding is well established to avoid the development of nipple
confusion. Slats in a crib should be no more than 2 inches apart.
The nurse is providing information about caring for the infant at home after discharge. What teaching
by the nurse is appropriate if the infant has a "common cold?"
→ Hold the infant in an upright position when feeding.
Use a pillow to raise the head when sleeping.
Ensure the infant is fully dressed with warm
clothes. Ensure the infant receives frequent
large feedings.
The nurse must teach the parents to hold the infant in an upright position when feeding to relieve the
discomfort from accumulated secretions. The nurse must teach the parents to avoid use of a pillow to
raise the infant’s head. The head of the mattress must be elevated by 30 degrees to raise the infant’s
head and chest. The nurse must teach the parents not to overdress the infant, but to avoid drafts. The
infant must be fed frequently in small amounts to prevent overtiring.
p. 590
A client with a history of gonorrheal infection has just delivered a baby. What immediate intervention
should the nurse provide to the newborn to ensure safety?
Place the newborn in incubator.
→ Administer ophthalmic solution.
, Perform a heelstick puncture test.
Provide ventilator support to the
newborn.
The nurse should administer erythromycin ophthalmic solution to the newborn within 2 hours of birth to
prevent ophthalmia neonatorum caused by gonorrheal infection. Incubation is preferred when a
neonate has hypothermia in order to regulate the body temperature. Heelstick puncture is performed to
detect abnormalities in blood levels only if the neonate has any infection. Ventilator support is provided
if the neonate’s heart rate is below 100 beats/minute.
However, the heart rate is not decreased due to gonorrheal infection.
p. 568
, The nurse is using the CRIES pain scale to determine the pain level in a circumcised infant. What does
a score of 1 for "Sleeplessness" indicate?
The infant has been constantly
awake. The infant has been asleep
for an hour.
The infant has awakened only when touched.
→ The infant has awakened at frequent intervals.
If the infant has awakened at frequent intervals in the past hour, the "Sleeplessness" score is 1. The
score is 2 for the infant who has been constantly awake. The score is 0 for the infant who has been
asleep for an hour or sleeps well and awakens only when touched.
p. 584
Which statement provides helpful and accurate nursing advice concerning bathing
the newborn?
Newborns should be bathed every day, for the bonding as well as the cleaning.
→ Tub baths may be given before the infant’s umbilical cord falls off and the
umbilicus is healed.
Only plain warm water can be used to preserve the skin’s acid mantle.
→ Powders are not recommended because the infant can inhale powder.
Bathe immediately after feeding while baby is calm and relaxed.
Tub baths may be given as soon as an infant’s temperature has stabilized. Powder is not
recommended because of the risk of inhalation. If a parent chooses to use baby powder, it should
never be sprinkled directly onto the baby’s skin. The parent can apply a small amount of powder to
his or her own hand and then apply to the infant. Newborns do not need a bath every day, even if the
parents enjoy it. The diaper area and creases under the arms and neck need more attention.
Unscented mild soap is appropriate to use to wash the infant. Do not bathe immediately after a
feeding period because the increased handling may cause regurgitation.
Which interventions should the nurse perform to differentiate between cutaneous jaundice and normal
skin color in the newborn?
Blanch the skin with two fingers.
→ Apply pressure over the forehead.
Assess the skin color in bright light.
→ Use transcutaneous bilirubinometry.
→ Assess the color of the conjunctival sacs.
The nurse applies pressure with a finger over a bony area such as the forehead, nose, or sternum for
several seconds to empty all the capillaries in that spot. The blanched area will appear yellowish
before the capillaries refill if the newborn has jaundice. The nurse may use transcutaneous
bilirubinometry (TcB), which is a more accurate noninvasive assessment of hyperbilirubinemia. It
allows for repetitive estimations of bilirubin and works well on both dark and light-skinned infants. The
nurse assesses the conjunctival sacs and buccal mucosa of darker-skinned infants for yellow
coloration. While assessing the infant for birth trauma, the nurse differentiates hemorrhagic areas
from a skin rash or discolorations by blanching the skin with two fingers. This intervention does not
help in assessing the skin color. The nurse must assess the newborn in natural light because artificial
lighting and reflection from nursery walls can distort the actual skin color.
The nurse is performing a pulse oximetry test to assess a newborn for congenital heart defects. What
must the nurse bear in mind while performing this test?
The screening test is performed after 48 hours of age.
→ The test is performed in the newborn’s right hand and on one foot.
The infant has passed if oxygen saturation is greater than 80%.
The infant is evaluated in case of a 10% difference in the extremities.
The pulse oximetry test is a noninvasive screening test used to measure oxygen saturation. It is
performed in the right hand and on one foot of the newborn. Hypoxemia can be the first sign that a
congenital heart defect is present, so the test is performed at 24 to 48 hours of age. The infant
passes the test only if the oxygen saturation is greater than 95% in either extremity. There must be
no more than 3% difference between the upper and lower extremity readings. Immediate evaluation
is needed if the oxygen saturation is less than 90%.
p. 576
The nurse is caring for a full term infant immediately after birth. The infant is crying and has good
muscle tone. What interventions should the nurse perform for this infant?
→ Assess the airway and keep the neck slightly extended.
Wash the infant with warm water and wrap in a towel.
→ Assess the heart rate by grasping the base of the cord.
