ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 of 5
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?
Correct Answer: B
Rationale: The correct answer is B: Chin quivering. Chin quivering is a common sign of pain in newborns. It indicates discomfort and distress. Decreased heart rate (choice
A), pinpoint pupils (choice
C), and slowed respirations (choice
D) are not typical signs of pain in newborns. Decreased heart rate may indicate relaxation, pinpoint pupils may suggest neurological issues, and slowed respirations may be a response to other factors.
Therefore, the most appropriate finding indicating pain in this scenario is chin quivering.
Question 2 of 5
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: FHR 152/min. At 18 weeks gestation, the fetal heart rate (FHR) typically ranges from 140-160 beats per minute, making 152/min within the normal range. This finding indicates a healthy fetal heart rate.
A: Deep tendon reflexes 4+ is not relevant to a routine assessment at 18 weeks gestation.
B: Fundal height of 14 cm is more indicative of around 12 weeks gestation, not 18 weeks.
C: Blood pressure of 142/94 mm Hg is elevated and would require further assessment and management, not expected at 18 weeks gestation.
In summary, the FHR of 152/min is the expected finding at 18 weeks gestation, making it the correct answer.
Question 3 of 5
A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct action for the nurse to take first is to determine respiratory function (
Choice
A). This is because an unresponsive client may be experiencing respiratory distress, which is a life-threatening situation requiring immediate intervention. Assessing respiratory function will help the nurse identify if the client is breathing adequately or if there is a need for immediate respiratory support such as airway management or assisted ventilation.
Increasing the IV fluid rate (
Choice
B), accessing emergency medications (
Choice
C), and collecting a blood sample for coagulopathy studies (
Choice
D) are important interventions but are not the priority in this scenario. Respiratory function takes precedence as airway and breathing are essential for life and must be addressed first to ensure the client's safety and well-being.
Question 4 of 5
A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include?
Correct Answer: D
Rationale:
Rationale: The correct answer is D because pressing the handheld button when feeling the baby move helps monitor fetal heart rate and movements during the test. This action allows healthcare providers to assess the baby's well-being.
Choice A is incorrect as the test duration varies.
Choice B is wrong as the client should lay on their left side, not supine, to prevent compression of the vena cava.
Choice C is incorrect as eating and drinking are not restricted before the test.
Question 5 of 5
A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?
Correct Answer: A
Rationale: The correct answer is A. Levonorgestrel is an emergency contraception pill effective if taken within 72 hours post unprotected sex. This is crucial information for the adolescent to prevent pregnancy.
Choice B is incorrect as it does not interact with oral contraceptives.
Choice C is incorrect as missing a period does not necessarily indicate pregnancy.
Choice D is incorrect as it only provides immediate protection, not for 14 days.