ATI Maternal newborn 2
A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level.
What action should the nurse take?
a. apply barrier ointment to the newborn's perianal region
b. offer the newborn glucose water between feedings
c. use photometer to monitor the lamp's energy
d. keep the newborn's eye patches on during feedings - Answer--c. use photometer to monitor the
lamp's energy
the nurse should monitor the lamp's energy throughout the therapy to ensure the newborn is receiving
the appropriate amount to be effective
A nurse is assessing a 4 hr old newborn who is to breastfeed and notes hands and feet that are cool and
slightly blue What action should the nurse take?
a. check the newborns temp using temporal thermometer
b. place the naked newborn on the mothers bare chest and cover both with a blanket
c. apply an o2 hood over the newborns head and neck
d. give the newborn glucose water between feedings - Answer--b. place the naked newborn on the
mothers bare chest and cover both with a blanket
A nurse is assessing a client who is 14 hr postpartum and has a 3rd degree perineal laceration. The
client's temp is 37.8 C (100F), her fundus is firm and slightly deviated to the right. The client reports a
gush of blood when she ambulates and no bm since delivery. What action should the nurse take?
a. notify the provider about the elevated temp
, b. massage the client's fundus
c. administer bisacodyl supp
d. assist the client to empty her bladder - Answer--d. assist the client to empty her bladder
When the client's fundus is deviated to the right or left it can indicate that her bladder is full. The nurse
should assist the client to empty her bladder to prevent uterine atony and excessive lochia.
A nurse is preparing to administer morphine oral solution 0.04 mg/kg to a newborn who weighs 2.5kg.
The amount available is 0.4 mg/ml. how many ml should the nurse administer? - Answer--0.25
Exposure to a cool environment causes vasoconstriction, which results in cool extremities with a bluish
discoloration. Placing the newborn skin-to-skin with his mother helps stabilize his temperature and
promotes bonding.
A nurse is caring for a newborn immediately following delivery. What actions should the nurse take
first?
a. place the newborn directly on the client's chest
b. administer erythromycin ophthalmic ointment
c. give the newborn vit K IM
d. perform a detailed physical assessment - Answer--a. place the newborn directly on the client's chest
The nurse should apply the safety and risk reduction priority-setting framework when caring for this
client. This framework assigns priority to the factor or situation posing the greatest safety risk to the
client. When there are several risks to client safety, the one posing the greatest threat is the highest
priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or
nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the greatest
risk to the newborn is cold stress, which increases the need for oxygen and glucose. Placing the newborn
directly on the client's chest will help maintain the newborn's temperature.
A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level.
What action should the nurse take?
a. apply barrier ointment to the newborn's perianal region
b. offer the newborn glucose water between feedings
c. use photometer to monitor the lamp's energy
d. keep the newborn's eye patches on during feedings - Answer--c. use photometer to monitor the
lamp's energy
the nurse should monitor the lamp's energy throughout the therapy to ensure the newborn is receiving
the appropriate amount to be effective
A nurse is assessing a 4 hr old newborn who is to breastfeed and notes hands and feet that are cool and
slightly blue What action should the nurse take?
a. check the newborns temp using temporal thermometer
b. place the naked newborn on the mothers bare chest and cover both with a blanket
c. apply an o2 hood over the newborns head and neck
d. give the newborn glucose water between feedings - Answer--b. place the naked newborn on the
mothers bare chest and cover both with a blanket
A nurse is assessing a client who is 14 hr postpartum and has a 3rd degree perineal laceration. The
client's temp is 37.8 C (100F), her fundus is firm and slightly deviated to the right. The client reports a
gush of blood when she ambulates and no bm since delivery. What action should the nurse take?
a. notify the provider about the elevated temp
, b. massage the client's fundus
c. administer bisacodyl supp
d. assist the client to empty her bladder - Answer--d. assist the client to empty her bladder
When the client's fundus is deviated to the right or left it can indicate that her bladder is full. The nurse
should assist the client to empty her bladder to prevent uterine atony and excessive lochia.
A nurse is preparing to administer morphine oral solution 0.04 mg/kg to a newborn who weighs 2.5kg.
The amount available is 0.4 mg/ml. how many ml should the nurse administer? - Answer--0.25
Exposure to a cool environment causes vasoconstriction, which results in cool extremities with a bluish
discoloration. Placing the newborn skin-to-skin with his mother helps stabilize his temperature and
promotes bonding.
A nurse is caring for a newborn immediately following delivery. What actions should the nurse take
first?
a. place the newborn directly on the client's chest
b. administer erythromycin ophthalmic ointment
c. give the newborn vit K IM
d. perform a detailed physical assessment - Answer--a. place the newborn directly on the client's chest
The nurse should apply the safety and risk reduction priority-setting framework when caring for this
client. This framework assigns priority to the factor or situation posing the greatest safety risk to the
client. When there are several risks to client safety, the one posing the greatest threat is the highest
priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or
nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the greatest
risk to the newborn is cold stress, which increases the need for oxygen and glucose. Placing the newborn
directly on the client's chest will help maintain the newborn's temperature.
