RN ATI Maternal Proctored Exam 2023-2024 with NGN -Nurselytic

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RN ATI Maternal Proctored Exam 2023-2024 with NGN Questions

Extract:


Question 1 of 5

A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?

Correct Answer: A

Rationale: The correct answer is A: Administer the injection into the vastus lateralis muscle. For newborns, the vastus lateralis muscle is the preferred site for intramuscular injections due to its size and well-developed muscle mass, ensuring proper absorption and minimizing the risk of injury to surrounding structures. Administering the vaccine into this muscle also helps improve vaccine efficacy.

Choices B, C, and D are incorrect.
Choice B, vigorously massaging the site, can cause discomfort, bruising, and potential tissue damage.
Choice C, inserting the needle at a 45° angle, is not recommended for intramuscular injections as the needle should be inserted at a 90° angle to ensure proper delivery into the muscle.
Choice D, using a 21-gauge needle, is not specific for newborns and can be too large for their small muscle mass, causing unnecessary pain and potential tissue damage.

Question 2 of 5

A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?

Correct Answer: D

Rationale: The correct answer is D: Administer 500 mL lactated Ringer’s IV bolus. This action is necessary to address the persistent vaginal bleeding after cesarean birth, as it could be a sign of postpartum hemorrhage. Administering IV fluids helps to improve circulating volume and maintain adequate perfusion to vital organs. This can help stabilize the client's condition while further assessments and interventions are carried out.


Choice A: Replacing the surgical dressing does not address the underlying cause of the bleeding and is not a priority at this time.

Choice B: Evaluating urinary output is important but not the immediate action needed to address the vaginal bleeding.

Choice C: Applying an ice pack to the incision site is not appropriate for controlling postpartum bleeding.
In summary, administering IV fluids is the priority to address potential postpartum hemorrhage, while the other options do not directly address the urgent issue at hand.

Question 3 of 5

A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?

Correct Answer: D

Rationale: The correct answer is D: Jitteriness. Neonates born to mothers with gestational diabetes are at risk for hypoglycemia due to the abrupt cessation of the maternal glucose supply postnatally. Jitteriness is a common manifestation of hypoglycemia in newborns. It is important for the nurse to monitor for this sign as it indicates the need for prompt intervention to prevent further complications. Abdominal distention, petechiae, and increased muscle tone are not typically associated with hypoglycemia in newborns born to mothers with gestational diabetes.

Question 4 of 5

A nurse is collecting data from a client who is at 30 weeks of gestation. Which of the following findings should the nurse identify as a manifestation of pyelonephritis?

Correct Answer: B

Rationale: The correct answer is B: Flank pain. Pyelonephritis is a kidney infection commonly characterized by flank pain, which is a key symptom. Flank pain is typically located on the side of the body between the upper abdomen and the back. This pain occurs due to inflammation of the kidney tissues. The other choices are incorrect because:
A) Epigastric discomfort is more indicative of issues related to the upper abdomen, such as gastritis or pancreatitis.
C) A temperature of 37.7°C (99.8°F) is slightly elevated but not specific to pyelonephritis.
D) Abdominal cramping is more suggestive of gastrointestinal issues like gas or constipation.
Therefore, the presence of flank pain is the most relevant finding to identify pyelonephritis in a client at 30 weeks of gestation.

Question 5 of 5

A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique. Which of the following information should the nurse include?

Correct Answer: D

Rationale: The correct answer is D: Notify the provider if the end of your baby’s penis appears dark red. This is important to monitor for signs of infection, such as redness, swelling, or discharge. Yellow exudate forming in 24 hours (
C) is incorrect as it may indicate infection. The Plastibell is typically removed after a few days, not 4 hours (
A). Ensuring a snug diaper (
B) is irrelevant to the circumcision technique.

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