ATI

Question 1

Erythema toxicum (erythema neonatorum):

Answer 1

a pink rash that appears suddenly anywhere on the body of a term newborn during the first 3 weeks. This is frequently referred to as newborn rash. No treatment is required.

Question 2

Normal temp range:

Answer 2

36.5° C to 37.5° C (97.7°F to 99.5°F) axillary.

Question 3

Telangiectatic nevi (stork bites):

Answer 3

flat pink or red marks that easily blanch and are found on the back of the neck, nose, upper eyelids, and middle of the forehead.

Question 4

Bulging fontanels can indicate:

Answer 4

increased intracranial pressure, infection, or hemorrhage

Question 5

Cephalohematoma:

Answer 5

is a collection of blood between the periosteum and the skull bone that it covers. It does not cross the suture line. It results from trauma during birth such as pressure of the fetal head against the maternal pelvis in a prolonged difficult labor or forceps delivery. It appears in the first 1 to 2 days after birth and resolves in 2 to 3 weeks.

Question 6

Subconjunctival hemorrhages can result from…

Answer 6

pressure during birth

Question 7

Meconium should be passed within…

Answer 7

24-48 hrs after birth

Question 8

Urine should be passed within…

Answer 8

24 hr after birth. Uric acid crystals will produce a rust color in the urine the first couple of days of life.

Question 9

Expected lab values:
Hgb
Platelets
Hct
Glucose
RBC
Leukocytes

Answer 9

Hgb: 14-24 g/dL
Platelets: 150,000 - 300,000
Hct: 44% - 64%
Glucose: 40 - 60 mg/dL
RBC: 4.8 - 7.1
Leukocytes: 9,000 - 30,000

Question 10

Bilirubin:
24 hour
48 hour
3-5 days

Answer 10

24 hr: 2 - 6 mg/dL
48 hr: 6 - 7 mg/dL
3-5 days: 4 - 6 mg/dL

Question 11

Bulb suctioning:

Answer 11

Compress before inserting into mouth.

Mouth first, then nostrils.

Question 12

Bathing:

Answer 12

Once newborn has stabilized temp of at least 36.5° C (97.7° F).
Sponge bath in first 1-2 hr after birth under heat.
Complete bathing performed 2-3 times per week using mild soap without hexachlorophene.

Question 13

Newborns should void once within…

Then how frequently?

Answer 13

24 hr of birth. They should void 6 to 8 times per 24 hr after day 4.

Question 14

Meconium should be passed within…

Then how frequently?

Answer 14

the first 24-48 hr after birth. The newborn will then continue to pass stool 3-4 times a day depending on breast‑ or bottle‑fed.

Question 15

The stools of newborns who are breastfed….

The stools of newborns who are formula‑fed….

Answer 15

Breastfed: can appear yellow and seedy. They should have at least 3 stools per day for the first month.
Formula-fed: lighter in color and looser

Question 16

Cord clamp:

When does it fall off?

Answer 16

stays in place for 24 to 48 hr. Bathing infant by submerging in water should not occur until the cord has fallen off. Most cords fall off within the 10 to 14 days.

Question 17

For mothers infected with hepatitis B, hepatitis B immunoglobulin and the hepatitis B vaccine is given within…

Answer 17

12 hr of birth. The hepatitis B vaccine is given alone at 1 month, 2 months, and 12 months.

Question 18

Hypoglycemia signs:

Answer 18

Jitteriness; twitching; a weak, high‑pitched cry; irregular respiratory effort; cyanosis; lethargy; eye rolling; seizures; and a blood glucose level less than 40 mg/dL by heel stick.

Question 19

Rho(D) immune globulin is administered within…

Answer 19

72 hr to women who are Rh-negative and gave birth to infants who are Rh-positive to prevent sensitization in future pregnancies.

Question 20

When to get these vaccinations:
Rubella
Hep B
Rh
Varicella
TDAP

Answer 20

Rubella: after
Hep B: within 12 hr after birth
Rh: within 72 hr of being born
Varicella: after
TDAP: during

Question 21

Routine tests

Blood type, Rh, & antibodies:

Answer 21

24-28 weeks

Question 22

Routine tests

CBC with differential, Hgb, Hct:

Answer 22

Detects infection and anemia

Question 23

Routine tests

Hgb electrophoresis:

Answer 23

Identifies hemoglobinopathies (sickle cell anemia)

Question 24

Routine tests

Group B strep (GBS):

Answer 24

35-37 weeks

Question 25

Routine tests

One-hour glucose tolerance:

Answer 25

24-28 weeks

Question 26

TDAP:

Answer 26

27-36 weeks

Question 27

Circumcision care:

Answer 27

Change newborn’s diaper at least every 4 hr. Clean the penis with warm water with each diaper change. Apply petroleum jelly with each diaper change for at least 24 hr after the circumcision. Will heal completely within a couple weeks.

Question 28

CST:

Answer 28

FHR is measured for about 20 min before the CST to detect baseline variability and to detect any FHR alterations without induced stress.

Question 29

Stages of labor:
1st
2nd
3rd
4th

Answer 29

1st: 1cm-10cm
2nd: pushing & birth
3rd: delivery of baby & placenta
4th: placenta & maternal stabilization

Question 30

Ovulation occurs…

Answer 30

27-75 days after birth

Question 31

Menses resume…

Answer 31

by 4 to 6 weeks postpartum

Question 32

Vertex presentation:

Answer 32

Fetal heart tones should be assessed below the mother’s umbilicus in either the right- or left-lower quadrant of the abdomen.

Question 33

Breech presentation:

Answer 33

Fetal heart tones should be assessed above the mother’s umbilicus in either the right- or left-upper quadrant of the abdomen.

Question 34

Varicose veins and lower-extremity edema can occur…

Answer 34

during the second and third trimesters. The client should rest with her legs elevated, avoid constricting clothing, wear support hose, avoid sitting or standing in one position for extended periods of time, and not sit with her legs crossed at the knees.

Question 35

Lochia rubra:

Lasts how long?

Answer 35

bright red color, bloody consistency, fleshy odor, can contain small clots, transient flow increases during breastfeeding and upon rising. Lasts 1 to 3 days after delivery.

Question 36

Lochia serosa:

Lasts how long?

Answer 36

pinkish brown color and serosanguineous consistency. Lasts from approximately day 4 to day 10 after delivery.

Question 37

Lochia alba:

Lasts how long?

Answer 37

yellowish white creamy color, fleshy odor. Lasts from approximately day 11 up to 4 to 8 weeks postpartum.

Question 38

Perineal tenderness, laceration, and episiotomy care:

Answer 38

Apply ice packs to the perineum for the first 24 to 48 hr to reduce edema and provide anesthetic effect. Encourage sitz baths at a temperature of 38° to 40° C (100° to 104° F) or cooler at least twice a day.

Question 39

Colostrum:
Milk:

Answer 39

Colostrum: pregnancy until 2-3 after delivery
Milk: 3-5 days after delivery

Question 40

Amniocentesis:

Answer 40

can be done after 14 weeks. AFP can be measured 15-20 weeks.

Question 41

Hypoglycemia findings:

Answer 41

Less than 40mg/dL
LGA or SGA
Poor feeding
Jitteriness/tremors
Hypothermia
Weak cry
Lethargy
Flaccid muscle tone
Seizures/coma
Irregular respirations
Cyanosis
Apnea

Question 42

Ectopic pregnancy findings:

Answer 42

• Unilateral stabbing pain & tenderness in the lower-abdomen quadrant
• Delayed (1-2 weeks) irregular menses
• Scant, dark red, or brown vaginal spotting 6-8 weeks after last normal menses
• Red, vaginal bleeding if rupture has occurred
• Referred shoulder pain due to blood in peritoneal cavity near phrenic nerve
• Faintness and dizziness
• Hemorrhage and shock (hypotension, tachycardia, pallor)

Question 43

Placenta previa findings:

Answer 43

• Painless, bright red bleeding during 2nd or 3rd trimester
• Uterus soft, relaxed, and nontender
• Fundal height greater than usual
• Fetus breech, oblique, or transverse
• Reassuring FHR
• Vital signs within normal limits
• Decreasing urinary output can be a better indicator of blood loss

Question 44

Abruptio placentae findings:

Answer 44

• Sudden onset of intense localized uterine pain with dark red vaginal bleeding
• Area of uterine tenderness can be localized or diffuse over uterus and boardlike
• Contractions with hypertonicity
• Fetal distress
• Hypovolemic shock

Question 45

Prolapsed cord care:

Answer 45

• Reposition the client in a knee-chest, Trendelenburg, or a side-lying position with a rolled towel under the client’s right or left hip to relieve pressure on the cord.
• Apply a warm, sterile, saline-soaked towel to the visible cord to prevent drying and to maintain blood flow.