ATI Maternal Newborn

Correct Answer: C

Rationale: The Apgar score is calculated based on five parameters: heart rate, respiratory effort, muscle tone, reflex irritability, and color. In this case, the newborn's findings at 1 minute after delivery indicate a heart rate >100/min (2 points), slow, weak cry (1 point), some flexion of extremities (1 point), grimace in response to suctioning (1 point), and body pink with blue extremities (1 point). Adding these points together results in a total Apgar score of 6, reflecting the newborn's initial assessment for their overall well-being. Choice A (4) is too low based on the given findings, while Choice B (5) is also lower than the correct score of 6. Choice D (7) is too high as it would require additional findings to reach that score.

Correct Answer: B

Rationale: In a situation where a client has postpartum psychosis, the priority action for the nurse is to ask the client if they have thoughts of harming themselves or their infant. This is crucial to assess the risk of harm and ensure the safety of the client and the infant. While reinforcing the importance of taking antipsychotics as prescribed is essential for treatment, safety concerns take precedence. Monitoring the infant for signs of failure to thrive is important for the infant's well-being but is not the priority when the immediate safety of the client and infant is at risk. Checking the client's medical record for a history of bipolar disorder is relevant for understanding the client's medical history but is not the priority when addressing current safety concerns.

Correct Answer: C

Rationale: The Apgar score is calculated based on five parameters: heart rate, respiratory effort, muscle tone, reflex irritability, and color. In this case, the newborn's findings at 1 minute after delivery indicate a heart rate >100/min (2 points), slow, weak cry (1 point), some flexion of extremities (1 point), grimace in response to suctioning (1 point), and body pink with blue extremities (1 point). Adding these points together results in a total Apgar score of 6, reflecting the newborn's initial assessment for their overall well-being. Choice A (4) is too low based on the given findings, while Choice B (5) is also lower than the correct score of 6. Choice D (7) is too high as it would require additional findings to reach that score.

Correct Answer: D

Rationale: A displaced and boggy fundus in a postpartum client typically indicates a full bladder, which can impede uterine contractions and increase the risk of postpartum hemorrhage. Assisting the client to the bathroom to void helps ensure the bladder is empty, aiding the fundus to contract and reducing the risk of complications. Encouraging Kegel exercises, changing positions, or assessing pain would not directly address the issue of the boggy fundus caused by a full bladder.

Correct Answer: C

Rationale: The correct answer is C because cleaning the penis with each diaper change is essential for preventing infection and promoting healing after circumcision. This practice helps maintain good hygiene and reduces the risk of complications. Removing the yellow mucus or giving a tub bath too soon can interfere with the healing process and increase the likelihood of infection. Choice A is incorrect because circumcision healing usually takes about a week or more, not just a couple of days. Choice B is incorrect because parents should gently clean the area, including removing any discharge or debris as part of proper care. Choice D is incorrect because tub baths should be avoided until the circumcision is fully healed to prevent infection.