ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake 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. This is the recommended site for administering vaccines to newborns due to the large muscle mass, reducing the risk of injury to nerves and blood vessels. It also allows for proper absorption of the vaccine. Option B is incorrect as vigorous massage can lead to tissue damage and discomfort. Option C is incorrect as the needle should be inserted at a 90° angle for intramuscular injections. Option D is incorrect as a smaller gauge needle (typically 25-27 gauge) is recommended for newborns to minimize pain and tissue trauma.
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 ongoing vaginal bleeding after cesarean birth, which may indicate hypovolemia or postpartum hemorrhage. Administering IV fluids helps to restore circulating volume and maintain adequate perfusion to prevent further complications.
Replacing the surgical dressing (
A) does not address the underlying issue of vaginal bleeding. Evaluating urinary output (
B) is important for assessing renal function but is not the priority in this situation. Applying an ice pack to the incision site (
C) is not appropriate for treating postpartum bleeding. Administering a lactated Ringer’s IV bolus (
D) is the most urgent intervention to manage the ongoing bleeding and prevent further complications.
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. In newborns of mothers with gestational diabetes, they are at risk for hypoglycemia due to the sudden drop in glucose levels after birth. Jitteriness is a common manifestation of hypoglycemia in newborns, indicating neurological impairment. Abdominal distention (
A) is not typically associated with hypoglycemia. Petechiae (
B) are tiny red or purple spots on the skin and are not specific to hypoglycemia. Increased muscle tone (
C) is more commonly seen in conditions like cerebral palsy. Jitteriness (
D) is a typical sign of hypoglycemia in newborns and requires prompt attention to prevent further complications.
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 an infection of the kidneys commonly characterized by flank pain. At 30 weeks of gestation, the uterus enlarges and can lead to obstruction of the ureters, increasing the risk of urinary stasis and infection. Epigastric discomfort (choice
A) is more indicative of issues like preeclampsia. Temperature elevation (choice
C) can be a sign of infection but is not specific to pyelonephritis. Abdominal cramping (choice
D) is more likely related to uterine contractions or gastrointestinal issues.
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:
Correct
Answer: D. Notify the provider if the end of your baby’s penis appears dark red.
Rationale: Dark red appearance at the end of the baby's penis could indicate infection or poor blood flow, requiring immediate medical attention to prevent complications. This information is crucial for parents to recognize potential risks post-circumcision.
Summary of other choices:
A: The Plastibell is usually removed after a few days, not 4 hours. Incorrect.
B: Snug diapers can cause irritation. Not relevant to Plastibell circumcision. Incorrect.
C: Yellow exudate forming in 24 hours is normal post-circumcision. Not concerning. Incorrect.