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 caring for a client who is at 30 weeks of gestation. The nurse should plan to immunize the client with which of the following vaccinations? Select all that apply.
Correct Answer: C,D
Rationale: The correct vaccinations for a pregnant client at 30 weeks gestation are C: Diphtheria-acellular pertussis (Tdap) and D: Inactivated influenza. Tdap is recommended during every pregnancy to protect the newborn from whooping cough, and influenza vaccine is safe and crucial to prevent flu-related complications. Varicella (
A) and Human papillomavirus (
B) vaccines are contraindicated during pregnancy due to potential risks to the fetus. Additionally, the incomplete choices (E, F, G) do not align with the recommended vaccinations during pregnancy.
Question 2 of 5
A nurse is caring for a client who has preterm labor and receiving magnesium sulfate by continuous IV infusion. Which of the following laboratory values should the nurse review during tocolytic therapy?
Correct Answer: D
Rationale: The correct answer is D: Serum medication level. Monitoring the serum medication level is crucial during tocolytic therapy with magnesium sulfate as it helps ensure the therapeutic range is maintained to prevent toxicity or inadequate effectiveness. Reviewing the indirect Coombs test (
A) is not necessary for monitoring tocolytic therapy. Checking liver enzymes (
B) and uric acid level (
C) are not directly related to magnesium sulfate therapy for preterm labor. In summary, monitoring the serum medication level is essential for the safety and efficacy of magnesium sulfate therapy.
Question 3 of 5
A nurse is caring for a client who reports spontaneous rupture. The nurse observed fetal bradycardia in the FHR tracing and notices the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following should the nurse take next?
Correct Answer: D
Rationale: The correct answer is D: Cover the umbilical cord with sterile saline saturated towel. This step is crucial to prevent compression of the umbilical cord and maintain blood flow to the fetus, reducing the risk of fetal distress. It also helps in preventing infection and protecting the exposed cord.
Choice A: Initiating an infusion of IV fluids is not the priority in this situation as the immediate concern is to protect the umbilical cord and ensure fetal well-being.
Choice B: Performing a vaginal examination could further worsen the situation by putting pressure on the umbilical cord, leading to decreased blood flow to the fetus.
Choice C: Administering oxygen is important in fetal distress, but covering the umbilical cord takes precedence in this case to prevent further complications.
In summary, covering the umbilical cord with a sterile saline-saturated towel is the correct action to protect the cord and maintain fetal perfusion.
Question 4 of 5
A nurse is caring for a client who is 36 weeks gestation and has MRSA. Which of the following isolation precautions should the nurse initiate?
Correct Answer: B
Rationale: The correct answer is B: Contact isolation. This is because MRSA is primarily spread through direct physical contact with the infected individual or contaminated surfaces. By implementing contact precautions, the nurse can prevent the spread of MRSA to other patients and healthcare workers. Droplet precautions (choice
A) are used for diseases spread through large respiratory droplets, such as influenza. Airborne precautions (choice
C) are for diseases transmitted through small respiratory droplets that remain suspended in the air, like tuberculosis. Protective environment (choice
D) is used for immunocompromised patients to protect them from environmental pathogens.
Therefore, the most appropriate precaution for a client with MRSA at 36 weeks gestation is contact isolation.
Question 5 of 5
A nurse is assessing a client who is 27 weeks of gestation and has pre-eclampsia. Which of the following findings should the nurse report to the provider?
Correct Answer: B
Rationale: The correct answer is B: Platelet count 60,000/mm³. In pre-eclampsia, there is a risk of developing HELLP syndrome, which includes hemolysis, elevated liver enzymes, and low platelet count. A platelet count of 60,000/mm³ indicates thrombocytopenia, a serious complication that can lead to bleeding and should be reported to the provider urgently.
Choices A, C, and D are within normal limits for a pregnant client and are not indicative of an immediate concern in pre-eclampsia.