ATI RN
RN Maternal Nursing OB Newborn 2023 2024 Exam Questions
Extract:
Question 1 of 5
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
Correct Answer: A
Rationale: The correct answer is A: Substernal retractions. Substernal retractions in a newborn can indicate respiratory distress, which is a critical finding that requires immediate attention from the provider to prevent complications. Acrocyanosis (
B) is a common finding in newborns and usually resolves on its own. Overlapping suture lines (
C) can be normal in newborns due to the molding process during birth. The head circumference of 33 cm (13 in) (
D) is within the normal range for a newborn.
Question 2 of 5
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
Correct Answer: D
Rationale: The correct answer is D: Respiratory distress. Hypoglycemia in a late preterm newborn can lead to inadequate energy supply to the respiratory muscles, resulting in respiratory distress. Hypertonia (
A) is not a typical manifestation of hypoglycemia in newborns. Increased feeding (
B) is a common response to hunger but not a direct indication of hypoglycemia. Hyperthermia (
C) is not a typical sign of hypoglycemia. In summary, respiratory distress is a key clinical manifestation of hypoglycemia in late preterm newborns, making it the correct choice.
Question 3 of 5
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
Correct Answer: C
Rationale:
Correct
Answer: C - Assist the client to empty their bladder.
Rationale: The client's uterus palpated to the right above the umbilicus indicates a full bladder displacing the uterus. A distended bladder can prevent the uterus from contracting effectively, leading to increased risk of postpartum hemorrhage. Emptying the bladder helps the uterus contract properly, reducing the risk of complications. This intervention directly addresses the underlying issue.
Incorrect
Choices:
A: Reassessing in 2 hours does not address the immediate concern of a full bladder causing uterine displacement.
B: Simethicone is used for gas relief and is not relevant in this situation.
D: Instructing the client to lie on their right side does not address the bladder distention issue.
E, F, G: Irrelevant as they do not address the specific problem of a full bladder causing uterine displacement.
Question 4 of 5
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
Correct Answer: C
Rationale: The correct answer is C: Remove all clothing from the newborn except the diaper. During phototherapy, the newborn's skin needs to be exposed to the light to effectively treat hyperbilirubinemia. Removing all clothing allows maximum skin exposure. Option A is incorrect as water does not help with phototherapy. Option B is incorrect as lotion can interfere with the effectiveness of the therapy. Option D is incorrect as a rash is a common side effect of phototherapy and discontinuing it would hinder treatment.
Question 5 of 5
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?
Correct Answer: D
Rationale: The correct answer is D: Instruct the client to press the provided button each time fetal movement is detected. In a nonstress test, the client is required to monitor fetal movements and press a button each time they are felt. This helps assess fetal well-being by measuring the heart rate in response to movement. This action is essential for the accurate interpretation of the test results. Maintaining the client NPO (
A) is not necessary for this procedure. Placing the client in a supine position (
B) can lead to decreased blood flow to the fetus. Instructing the client to massage the abdomen (
C) may interfere with the natural fetal movements being monitored.
Therefore, the correct action is to have the client press the button when fetal movement is detected to ensure an accurate assessment of fetal well-being.