ATI RN
ATI RN Maternal Newborn Latest Update. 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 to rotate the pelvis, allowing the baby's shoulder to dislodge. This action enlarges the pelvic outlet, facilitating the delivery of the baby. Applying pressure to the fundus (
A) or pressing on the suprapubic area (
B) are not appropriate interventions for shoulder dystocia. Moving the client onto their hands and knees (
C) may be helpful in some cases but is not the initial step for the McRoberts maneuver.
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 is to massage the client's fundus. This is because excessive vaginal bleeding postpartum can indicate uterine atony, which is a common cause of postpartum hemorrhage. By massaging the fundus, the nurse can help the uterus contract and prevent further bleeding. This intervention is crucial in managing postpartum hemorrhage. Administering oxytocin (choice
B) can help with uterine contractions, but massaging the fundus should be done first. Emptying the client's bladder (choice
C) is important to prevent uterine atony, but it is not the first priority in this situation. Providing oxygen (choice
D) is not directly related to managing postpartum bleeding and should not be the first action.
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:
Correct
Answer: B - Cover the umbilical cord with a sterile saline-saturated towel.
Rationale: Protruding umbilical cord is a medical emergency that can lead to cord compression and compromise blood flow to the baby, resulting in fetal distress. Covering the cord with a sterile saline-saturated towel helps to prevent cord compression and maintain blood flow until delivery can be expedited. This action ensures the baby continues to receive oxygen and nutrients.
Summary of Incorrect
Choices:
A: Performing a vaginal examination could further compress the cord and worsen the situation.
C: Administering oxygen may be beneficial for the mother but does not address the immediate risk to the baby from cord compression.
D: Initiating an IV infusion is important but does not address the urgent need to protect the umbilical cord.
E, F, G: No information provided.
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 symptoms such as irritability, high-pitched crying, tremors, and poor feeding due to withdrawal from substances the mother used during pregnancy. Excessive crying is a common manifestation of this syndrome. 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 indicate other neurological or developmental issues.
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 is because the lateral side of the finger has fewer nerve endings, which can reduce pain for the client. Puncturing the finger while still damp with antiseptic solution (
A) can dilute the blood sample and affect accuracy. Smearing the blood onto the reagent strip (
B) can lead to inaccurate results. Holding the finger above the heart prior to puncture (
C) can increase blood flow and dilute the sample. In summary, selecting the lateral side of the finger for puncture is the best option to minimize pain and ensure an accurate blood glucose reading.