ATI-MN ATI Maternal Newborn Exam - Set 5 - Part 1

Correct Answer: It is a normal finding

Bluish hands and feet with a pink body is acrocyanosis, a common and normal finding in the newborn during the first hours as circulation adjusts after birth. Option b is incorrect because acrocyanosis is a normal circulatory change, not a sign of a heart defect. Option c is incorrect because acrocyanosis is expected and does not require oxygen. Option d is incorrect because central cyanosis, not bluish extremities alone, would suggest a serious problem.

Correct Answer: At one and five minutes after birth

Apgar scoring is done at one and five minutes after birth to evaluate the newborn's heart rate, breathing, tone, reflexes, and color during the transition to life. Option a is incorrect because Apgar scoring uses set early time points, not an hour of repeated checks. Option b is incorrect because a single score does not capture how the newborn adapts over the first minutes. Option c is incorrect because the standard times are one and five minutes, not thirty and sixty minutes.

Correct Answer: A rate of 45 breaths per minute

A newborn respiratory rate of about 45 breaths per minute falls within the expected range, which spans roughly 30 to 60 breaths per minute. Option b is incorrect because a rate of 12 is far too slow for a newborn and requires immediate attention. Option c is incorrect because a rate of 75 is above the expected range and signals respiratory distress. Option d is incorrect because a rate of 20 is below the expected range and suggests respiratory depression.

Correct Answer: Suction the mouth before the nose

The nurse suctions the mouth before the nose, because suctioning the nose first can cause the newborn to gasp and aspirate secretions from the mouth. Option a is incorrect because the bulb is compressed before insertion, then released to gently draw out secretions. Option b is incorrect because inserting the bulb deeply can stimulate the gag reflex and injure tissue. Option d is incorrect because suctioning the nose first can trigger a gasp that draws mouth secretions into the lungs.

Correct Answer: A rate of 140 beats per minute

A newborn heart rate of about 140 beats per minute is within the expected range, which spans roughly 110 to 160 beats per minute at rest. Option b is incorrect because a rate of 90 is below the expected range and should be evaluated. Option c is incorrect because a rate of 70 is far too slow for a newborn and requires attention. Option d is incorrect because a sustained rate of 180 is above the expected resting range.

Correct Answer: Caput succedaneum

Soft scalp swelling that crosses the suture lines is caput succedaneum, which is caused by pressure during birth and usually resolves within a few days. Option a is incorrect because a cephalohematoma does not cross the suture lines and takes weeks to resolve. Option b is incorrect because molding is the shaping of the skull bones, not fluid swelling that crosses sutures. Option d is incorrect because craniosynostosis is premature fusion of sutures, not soft swelling from birth pressure.

Correct Answer: Small white spots on the nose

Small white spots on the nose and chin are milia, a normal newborn finding caused by blocked oil glands that disappear without treatment, so parents should not squeeze them. Option a is incorrect because widespread bruising is not an expected skin finding and may signal a problem. Option b is incorrect because yellow skin within the first day suggests pathologic jaundice that needs evaluation, not a normal variation. Option c is incorrect because pale, mottled skin can indicate poor perfusion or cold stress rather than a normal variation.

Correct Answer: Document the finding

Flat bluish-gray areas over the back and buttocks are Mongolian spots, a normal newborn finding, so the nurse simply documents them to avoid later confusion with bruising. Option b is incorrect because a warm compress is not needed for this harmless skin finding. Option c is incorrect because these spots are a normal pigmentation finding, not a sign of injury to report. Option d is incorrect because the spots do not affect movement and require no activity restriction.

Correct Answer: Reassure parents these are normal

Whitish-yellow cysts on the gums and palate are Epstein pearls, a normal newborn finding that resolves on its own, so the nurse reassures the parents. Option a is incorrect because these normal cysts do not require a culture. Option b is incorrect because Epstein pearls are a benign finding, not a sign of infection. Option c is incorrect because Epstein pearls do not interfere with feeding, so feedings continue.

Correct Answer: It is erythema toxicum, a normal rash

A blotchy rash with small pale bumps appearing in the first days is erythema toxicum, a harmless newborn rash that clears on its own without treatment. Option a is incorrect because this is a benign newborn rash, not a serious skin infection. Option b is incorrect because this rash is unrelated to hydration status. Option d is incorrect because erythema toxicum is a normal finding rather than an allergic reaction.

Correct Answer: Rooting reflex

Turning the head toward a touch on the cheek and beginning to suck is the rooting reflex, which helps the newborn locate the nipple for feeding. Option b is incorrect because the tonic neck reflex is the fencing posture when the head is turned to one side. Option c is incorrect because the Babinski reflex involves the toes fanning when the sole is stroked. Option d is incorrect because the Moro reflex is a startle response to a sudden change in position, not head-turning toward touch.

Correct Answer: Moro reflex

A symmetric startle response with the arms extending and then drawing back when the head drops slightly is the Moro reflex, an expected newborn finding. Option a is incorrect because the plantar grasp is the curling of toes when the sole is touched. Option b is incorrect because the stepping reflex is seen when the newborn is held upright with feet on a surface. Option d is incorrect because rooting is head-turning toward a cheek touch, not a startle response.

Correct Answer: It is an expected Babinski reflex

Fanning of the toes when the sole is stroked is a normal Babinski reflex in the newborn, which is expected and disappears later in infancy. Option a is incorrect because the Babinski reflex is expected at this age and does not need reporting. Option c is incorrect because this response is normal in newborns rather than a sign of injury. Option d is incorrect because this reflex assesses neurologic response, not the hips.

Correct Answer: The baby sees best at close range

Newborns see best at close range, about the distance of a caregiver's face during feeding, and prefer high-contrast patterns and faces. Option a is incorrect because newborns do not see clearly across a room; their best focus is close up. Option b is incorrect because newborns prefer high-contrast patterns rather than dull gray ones. Option c is incorrect because newborns can see, though their clearest focus is at a short distance.

Correct Answer: They are signs of respiratory distress

Nasal flaring and grunting are signs of respiratory distress in a newborn and require prompt assessment, since newborns are obligate nose breathers who tire easily. Option b is incorrect because flaring and grunting are not normal and signal the newborn is working hard to breathe. Option c is incorrect because these are respiratory warning signs, not cues of hunger. Option d is incorrect because flaring and grunting are abnormal whether awake or asleep.

Correct Answer: Dry the newborn right away

Drying the newborn immediately removes moisture from the skin and prevents heat loss through evaporation, a key step in maintaining temperature after birth. Option a is incorrect because a cold scale causes heat loss through conduction rather than preventing evaporation. Option b is incorrect because a fan increases heat loss by convection and would cool the newborn further. Option c is incorrect because placing the newborn near a window causes heat loss by radiation, not prevention of evaporative loss.

Correct Answer: Place the newborn skin-to-skin

Skin-to-skin contact is an effective first measure to warm a newborn, transferring heat from the parent while supporting bonding and stable temperature. Option a is incorrect because removing the hat increases heat loss from the head, which is the opposite of what is needed. Option c is incorrect because placing the newborn near a vent causes more heat loss by convection. Option d is incorrect because a cool bath would lower the temperature further and worsen cold stress.

Correct Answer: A large body surface area for their size

Newborns have a large body surface area relative to their weight, little insulating fat, and cannot shiver, so they lose heat easily and need protection from cold. Option a is incorrect because newborns cannot shiver effectively to generate heat. Option b is incorrect because newborns have a high metabolic rate, not a slow one. Option d is incorrect because newborns have little insulating fat, which is why they lose heat readily.

Correct Answer: Low blood glucose

Cold stress raises the newborn's oxygen and energy demands, which can use up glucose stores and lead to low blood glucose along with acidosis. Option a is incorrect because a stressed, cold newborn tends to feed poorly, not show increased appetite. Option c is incorrect because cold stress is linked with metabolic problems rather than high blood pressure. Option d is incorrect because cold stress increases the respiratory rate and metabolic demand rather than slowing the heart.

Correct Answer: To prevent bleeding

Newborns have low vitamin K at birth, so the injection helps the blood clot and prevents hemorrhagic disease of the newborn. Option b is incorrect because eye infection is prevented with erythromycin eye ointment, not vitamin K. Option c is incorrect because low blood sugar is managed with feeding or glucose, not vitamin K. Option d is incorrect because vitamin K supports clotting and does not prevent jaundice.