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 is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Assist the client in pulling their knees toward their abdomen. In shoulder dystocia, the McRoberts maneuver involves hyperflexing the mother's legs against her abdomen to help dislodge the impacted shoulder. This action widens the pelvic outlet, allowing for easier delivery of the baby. Applying pressure to the fundus (
A) does not address the shoulder dystocia. Pressing firmly on the suprapubic area (
B) may not be effective in resolving the shoulder dystocia. Moving the client onto their hands and knees (
C) may not provide the optimal position for resolving the shoulder dystocia.
Therefore, assisting the client in pulling their knees toward their abdomen (
D) is the most appropriate action to help alleviate the shoulder dystocia and facilitate the delivery of the baby.
Question 2 of 5
A nurse is assessing a client who is 1 hr postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct action for the nurse to take first in this situation is to massage the client's fundus. This is because excessive vaginal bleeding postpartum can indicate uterine atony, which is the most common cause of postpartum hemorrhage. Massaging the fundus helps stimulate uterine contractions, which will help to control the bleeding. It is important to address this issue promptly to prevent further complications. Administering oxytocin (choice
B) can also help with uterine contractions, but massaging the fundus should be done first. Emptying the client's bladder (choice
C) can relieve pressure on the uterus, but it is not the priority in this situation. Providing oxygen (choice
D) is not necessary unless the client is showing signs of hypoxia, which is not indicated in the scenario.
Question 3 of 5
A nurse is caring for a client who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following actions should the nurse take next?
Correct Answer: B
Rationale: The correct answer is B: Cover the umbilical cord with a sterile saline-saturated towel. This action is essential to prevent compression and drying of the umbilical cord, which could lead to fetal hypoxia and compromise fetal circulation. By covering the umbilical cord with a sterile saline-saturated towel, the nurse can protect the cord and maintain fetal perfusion until delivery can be expedited. Performing a vaginal examination (choice
A) could further compress the cord and worsen the situation. Administering oxygen (choice
C) may be beneficial but is not the priority in this urgent situation. Initiating IV fluids (choice
D) is not the immediate priority when fetal bradycardia and umbilical cord prolapse are present.
Question 4 of 5
A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Excessive crying. Neonatal abstinence syndrome is characterized by withdrawal symptoms in newborns due to exposure to drugs in utero. Excessive crying is a common manifestation of this syndrome as the newborn experiences discomfort and agitation. Diminished deep tendon reflexes (
A), decreased muscle tone (
C), and absent Moro reflex (
D) are not typically associated with neonatal abstinence syndrome. These findings may be seen in other conditions, but not specifically in newborns with this syndrome.
Question 5 of 5
A nurse is obtaining a 2-hr postprandial blood glucose from a client. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Select the lateral side of the finger for puncture. This choice is correct because the lateral side of the finger has fewer nerve endings, making it less painful for the client. It also minimizes the risk of injury to the client and provides an adequate blood sample for testing.
Explanation for other choices:
A: Puncturing the finger while still damp with antiseptic solution can dilute the blood sample, leading to inaccurate results.
B: Smearing the blood onto the reagent strip can cause contamination and inaccurate readings.
C: Holding the finger above the heart prior to puncture can lead to increased blood flow and affect the accuracy of the blood glucose reading.