ATI RN
RN ATI Maternal Newborn 2023 with NGN Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is at 10 weeks of gestation. Which of the following findings should the nurse report to the provider?
Correct Answer: A
Rationale: The correct answer is A. Frequent vomiting with weight loss of 3 lb in 1 week can indicate hyperemesis gravidarum, a severe form of nausea and vomiting during pregnancy that can lead to dehydration and electrolyte imbalances. This finding is concerning and requires immediate medical attention to prevent complications. Reporting this to the provider allows for timely intervention.
Other choices are incorrect:
B: Reports of mood swings are common during pregnancy due to hormonal changes and are not typically a cause for immediate concern.
C: Nosebleeds occurring approximately 3 times per week can be due to increased blood flow during pregnancy and are usually not a significant concern unless severe or persistent.
D: Increased vaginal discharge is a common symptom in early pregnancy due to hormonal changes and increased blood flow to the pelvic area. It is not typically an urgent issue unless accompanied by other symptoms like itching or foul odor.
Question 2 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 indicate respiratory distress in a newborn, which can be a serious issue requiring immediate medical attention. Acrocyanosis (choice
B) is a common finding in newborns and is not concerning. Overlapping suture lines (choice
C) can be normal in newborns and typically resolve on their own. A head circumference of 33 cm (13 in) (choice
D) is within the normal range for a newborn.
Question 3 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 respiratory distress due to decreased glucose levels affecting cellular function and energy production. Hypertonia (choice
A) is not typically associated with hypoglycemia in newborns. Increased feeding (choice
B) may be a response to hypoglycemia but is not a direct manifestation. Hyperthermia (choice
C) is not a common sign of hypoglycemia.
Therefore, the correct choice is D as it directly reflects the impact of low glucose levels on respiratory function.
Question 4 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: The correct answer is C: Assist the client to empty their bladder. After giving birth vaginally, the uterus should be midline and firm. Palpating it above the umbilicus and to the right indicates a full bladder displacing the uterus. Emptying the bladder will allow the uterus to return to its normal position. A: Reassessing in 2 hours is unnecessary as the issue is a full bladder. B: Administering simethicone is for gas relief and not relevant in this situation. D: Instructing the client to lie on their right side does not address the underlying issue of the full bladder.
Question 5 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. Removing all clothing from the newborn except the diaper during phototherapy is essential as it helps maximize the skin surface area exposed to the light, thus enhancing the effectiveness of the treatment. This allows for better absorption of the light by the skin, aiding in the breakdown of bilirubin.
A: Feeding the newborn water every 4 hours is not directly related to phototherapy for hyperbilirubinemia.
B: Applying lotion to the newborn's skin may interfere with the effectiveness of phototherapy and should be avoided.
D: Discontinuing therapy if a rash develops is not advisable, as a rash is a common side effect of phototherapy and does not necessarily require therapy cessation.