ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?
Correct Answer: D
Rationale: The correct answer is D: Urine negative for ketones. In hyperemesis gravidarum, excessive vomiting can lead to dehydration and ketosis. A negative urine ketone result indicates the client may not be adequately hydrated or receiving proper nutrition. This finding should be reported to the provider for further evaluation and intervention. Option A (Blood pressure 105/64 mm Hg) is within normal range for a pregnant woman. Option B (Heart rate 98/min) is slightly elevated but may be due to dehydration. Option C (Urine output of 280 mL within 8 hr) is inadequate and indicates poor fluid intake or excessive fluid loss. Reporting a negative urine ketone result is crucial to prevent further complications.
Question 2 of 5
A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider?
Correct Answer: B
Rationale: The correct answer is B because failure to pass meconium within 24-48 hours can indicate a bowel obstruction or other serious issue that needs immediate attention. A: Erythema toxicum is a common benign rash in newborns. C: Pink-tinged urine can be due to uric acid crystals and is normal in newborns. D: An axillary temperature of 37.7°C (99.9°F) is within normal range for a newborn.
Extract:
A nurse is caring for a client who is pregnant in an antepartum clinic.
Vital Signs
0900:
Temperature 36.6°C (97.9°F)
Heart rate 88/min
Respiratory rate 18/min
Blood pressure 130/70 mm Hg
Oxygen saturation 97% on room air
1000:
Heart rate 76/min
Respiratory rate 20/min
Blood pressure 138/68 mm Hg
Oxygen saturation 98% on room air
Question 3 of 5
Which of the following findings should the nurse report to the provider?Select the 3 findings that should be reported.
Correct Answer: A,B,D
Rationale: The correct answers to report to the provider are A, B, and D.
A: Uterine contractions - Significant contractions could indicate preterm labor.
B: Fetal heart rate - Abnormal fetal heart rate can indicate fetal distress.
D: Vaginal examination - Risk of infection or cervical changes need provider evaluation.
C: Gestational age - Routine information, not typically requiring immediate provider notification.
E: Maternal blood pressure - Important but not typically urgent unless severely abnormal.
Extract:
A nurse is caring for a newborn who is 70 hr old. Exhibit 1
Medical History
Newborn delivered by repeat cesarean birth at 40 weeks of gestation.
Birth weight 3,515 g (7 lb 12 oz)
Apgar scores 8 at 1 min and 9 at 5 min
Maternal history of methadone use during pregnancy.
Exhibit 2
Vital Signs
0700:
Heart rate 156/min
Respiratory rate 58/min
Temperature 37.2° C (98.9° F)
Oxygen saturation 98% on room air
1100:
Heart rate 160/min
Respiratory rate 60/min
Temperature 37.3° C (99.2° F)
Oxygen saturation 96% on room air
Exhibit 3
Physical Examination
1100:
Newborn is inconsolable with a high-pitched cry. Newborn sucks vigorously on pacifier but
breastfeeds poorly. Respirations unlabored. Lungs sound clear on auscultation. Increased muscle
tone with moderate to severe tremors when disturbed. Hyperactive Moro reflex noted. Several
loose stools today.
Exhibit 4
Diagnostic Results
Maternal urine toxicology screen positive for opiates (negative)
Newborn urine toxicology screen positive for opiates (negative)
Question 4 of 5
Which of the following findings should the nurse report to the provider? Select all that apply.
Correct Answer: C,D
Rationale: The nurse should report central nervous system (CNS) and gastrointestinal (GI) findings to the provider because changes in these systems can indicate serious health issues. CNS findings may suggest neurological problems, while GI findings could indicate digestive issues or potential complications. Reporting these findings promptly allows the provider to assess the patient's condition thoroughly and intervene if necessary. Respiratory and oxygen saturation findings are important but may not always require immediate intervention. Other choices are not directly related to critical health concerns that need urgent attention.
Extract:
A nurse is caring for a newborn who is 48 hr old.
Exhibit 1
Vital Signs
Day 2, 0900:
Heart rate 174/min
Respiratory rate 88/min
Temperature 36.1° C (97.0° F)
Oxygen saturation 97% on room air
Exhibit 2
Diagnostic Results
Day 1, 0800: Newborn results
Blood type: A+
Urine toxicology screen: positive marijuana
Day 2, 0800: Newborn results
Total bilirubin 10 mg/dL (1.0 to 12.0 mg/dL)
Day 2, 0915:
Blood glucose: 38 mg/dL (expected value greater than 40 to 45 gm/dL)
Complete the diagram by dragging from the choices below to specify what condition the client is
most likely experiencing, 2 actions the nurse should take to address that condition, and 2
parameters the nurse should monitor to assess the client’s progress.
Question 5 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Action to Take
Potential Condition
Parameter to Monitor
Correct Answer:
Rationale: Action to Take: A, B; Potential Condition: B; Parameter to Monitor: C, E. The correct answer is to place newborn skin to skin on birthing parent's chest (
A) to promote bonding and regulate temperature, and encourage breastfeeding (
B) for nutrition and immune benefits. The potential condition the client is most likely experiencing is Cold stress (
B), indicated by the need for phototherapy. The nurse should monitor Temperature (
C) for signs of hypothermia and Bilirubin level (E) to assess jaundice severity. These interventions and parameters address the client's most likely condition and provide comprehensive care.