ATI RN
RN ATI Maternal Newborn 2023 with NGN Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is to receive oxytocin to augment their labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
Correct Answer: A
Rationale: The correct answer is A: Late decelerations. Late decelerations indicate uteroplacental insufficiency, meaning the baby is not getting enough oxygen during contractions. Administering oxytocin, which can further stress the baby by increasing contractions, can worsen the situation. Late decelerations are a sign of fetal distress and require immediate intervention.
B: Moderate variability of the FHR is a normal finding and does not contraindicate the initiation of oxytocin.
C: Cessation of uterine dilation would suggest a potential issue with labor progress but does not directly contraindicate oxytocin.
D: Prolonged active phase of labor may warrant oxytocin to augment contractions but is not a contraindication itself.
Question 2 of 5
A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Verify the newborn's identification. This should be done first to ensure the right baby is receiving care. Confirming the identity helps prevent errors in medication administration and procedures. Checking the identification is crucial for patient safety. The other options are not the first priority in this scenario. A: Confirming the Apgar score can wait until after ensuring the correct baby is being cared for. C: Administering vitamin K is important, but verifying identification takes precedence. D: Determining obstetrical risk factors can be done later once the baby's identity is confirmed.
Question 3 of 5
A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?
Correct Answer: C
Rationale:
Correct
Answer: C - Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution.
Rationale: Continuous monitoring of blood pressure is crucial after administering epidural anesthesia to detect any potential hypotension, a common side effect. This frequent monitoring allows for prompt intervention if hypotension occurs, ensuring the client's safety. It is essential to closely monitor the client's vital signs, particularly blood pressure, to prevent complications such as decreased placental perfusion and fetal distress.
Summary:
A: Placing the client in a supine position for 30 min following the first dose of anesthetic solution is not recommended as it can lead to aortocaval compression and compromise blood flow to the fetus.
B: Administering dextrose 5% in water prior to the first dose of anesthetic solution is not necessary for epidural anesthesia.
D: Ensuring the client has been NPO 4 hr prior to the placement of the epidural is
Question 4 of 5
A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take prior to leaving the newborn with their parent?
Correct Answer: A
Rationale:
Correct
Answer: A
Rationale: Ensuring that the parent's identification band number matches the newborn's identification band number is crucial for accurate identification. This step confirms that the parent is indeed the rightful guardian of the newborn, preventing mix-ups and ensuring the newborn's safety. Verifying the parent's identity through their name and date of birth (Option
B) is helpful but not as reliable as matching identification band numbers. Checking the newborn's security tag number (Option
C) is important for hospital security but does not directly verify the parent's identity. Matching the newborn's date and time of birth to the information in the parent's medical record (Option
D) is not as specific and reliable as matching identification band numbers.
Question 5 of 5
A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Have calcium gluconate readily available. Magnesium sulfate IV can cause toxicity leading to respiratory depression and cardiac arrest. Calcium gluconate is the antidote for magnesium sulfate toxicity as it antagonizes the effects of magnesium on the muscles. Having it readily available ensures prompt treatment in case of toxicity.
Restricting fluid intake (
A) is not necessary for preeclampsia and can lead to dehydration. Assessing deep tendon reflexes (
C) every 6 hours is important but not as crucial as having the antidote readily available. Monitoring intake and output (
D) every 4 hours is important for overall assessment but does not directly address magnesium sulfate toxicity.