ATI RN
ATI RN Maternal Newborn level 3 Final Exam 2023 (All Correct Answers). Maternal-Child Nursing Questions
Extract:
Question 1 of 5
A nurse is assessing a client who is in preterm labor and has a new prescription for terbutaline 0.25 mg subcutaneous. For which of the following findings should the nurse withhold the medication and report to the provider?
Correct Answer: B
Rationale:
Correct
Answer: B (Blood pressure 88/58 mmHg)
Rationale: Terbutaline is a tocolytic medication used to inhibit preterm labor contractions by relaxing uterine smooth muscle. A low blood pressure of 88/58 mmHg indicates hypotension, a potential side effect of terbutaline. Hypotension can lead to decreased perfusion to the fetus and maternal organs, warranting withholding the medication and notifying the provider for further evaluation and management.
Summary of Incorrect
Choices:
A: Fasting blood glucose 75 mg/dL - Normal blood glucose level, not a concerning finding related to terbutaline administration.
C: Urinary output 40 mL/hr - Normal urinary output, not a concerning finding related to terbutaline administration.
D: FHR 120/min - Normal fetal heart rate, not a concerning finding related to terbutaline administration.
Question 2 of 5
A nurse is providing teaching to the parents of a newborn about the plastibell circumcision technique.
Correct Answer: B
Rationale: The correct answer is B: Notify the provider if the end of the penis appears dark red. This is because dark red coloration at the end of the penis could indicate infection or compromised blood flow, requiring immediate medical attention.
Choice A is incorrect as the plastibell is typically left in place for about a week, not 4 hours.
Choice C is incorrect as a snug diaper can cause discomfort and hinder healing.
Choice D is incorrect because yellow exudate is a normal part of the healing process, usually appearing within 24-48 hours post-circumcision.
Question 3 of 5
A nurse is planning care immediately following birth for a newborn who has myelomeningocele that is leaking cerebrospinal fluid.
Correct Answer: A
Rationale: The correct answer is A. Administering broad-spectrum antibiotics is crucial to prevent infection since the exposed spinal cord increases the risk. Antibiotics help reduce the risk of meningitis and sepsis.
Choice B is incorrect as povidone-iodine can be irritating to the sensitive skin around the defect.
Choice C is incorrect as monitoring rectal temperature is not directly related to the immediate care needed for a myelomeningocele.
Choice D is incorrect because surgical closure should be done as soon as possible to prevent further complications.
Question 4 of 5
A nurse is caring for a newborn boy, 6 hours old, whose bedside glucose meter reading is 65 mg/dL. The newborn's mother has Type 2 diabetes mellitus.
Correct Answer: D
Rationale: The correct answer is D: Feed the newborn immediately. By feeding the newborn, the nurse can stimulate the release of insulin, which will help regulate the baby's blood sugar levels. This is important especially in the case of a newborn born to a mother with Type 2 diabetes mellitus, as the baby may be at risk for hypoglycemia. Administering IV dextrose solution (choice
A) is not necessary at this point as feeding is the initial intervention. Obtaining a blood sample for serum glucose level (choice
B) can be done later but immediate feeding takes precedence. Reassessing blood glucose prior to the next feeding (choice
C) may delay necessary intervention.
Question 5 of 5
A nurse is caring for four antepartum clients. Which of the following clients should the nurse assess first?
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client who is at 32 weeks of gestation and reports seeing floating spots first. Seeing floating spots could be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. Preeclampsia can lead to severe complications for both the mother and the baby if not managed promptly.
Therefore, this client needs immediate assessment to rule out preeclampsia and ensure appropriate interventions are initiated.
Choices A, C, and D do not present with urgent signs or symptoms that require immediate attention compared to the potential severity of preeclampsia in choice B.