ATI RN
ATI RN Maternal Newborn Latest Update. Questions
Extract:
Question 1 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 2 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 3 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.
Question 4 of 5
A nurse is assessing a newborn who was born postterm. Which of the following findings should the nurse expect?
Correct Answer: C
Rationale: The correct answer is C: Nails extending over tips of fingers. Postterm newborns tend to have longer nails due to the prolonged gestation period. This is because the nails continue to grow during the extra time in the womb. Large deposits of subcutaneous fat (
A) are more common in preterm infants. Thin covering of fine hair on shoulders and back (
B) is characteristic of lanugo, which is typically shed before birth. Pale, translucent skin (
D) is more commonly seen in premature babies.
Question 5 of 5
A nurse is teaching about car seat safety to the parents of a newborn who was delivered at 38 weeks of gestation. Which of the following statements by a parent indicates an understanding of the teaching?
Correct Answer: C
Rationale: The correct answer is C because positioning the car seat at a 45-degree angle is important for newborns to prevent their head from falling forward and potentially obstructing their airway. This angle helps keep the baby safe and secure during the ride.
Choice A is incorrect because using a sleep sack in the car seat can interfere with the harness straps and compromise the baby's safety.
Choice B is incorrect as a car seat challenge test is conducted for preterm infants, not infants born at 38 weeks of gestation.
Choice D is incorrect because it is recommended to keep infants in a rear-facing position until they reach the height or weight limit specified by the car seat manufacturer, typically around 2 years old.