ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 of 5
A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Facial petechiae. A nuchal cord occurs when the umbilical cord is wrapped around the baby's neck at birth. This can cause pressure on the baby's blood vessels, leading to tiny red or purple spots on the face called petechiae. This finding indicates possible trauma during delivery. Telangiectatic nevi (choice
A) are not typically associated with nuchal cords. Periauricular papillomas (choice
C) are benign growths near the ear and are unrelated to nuchal cords. Erythema toxicum (choice
D) is a common newborn rash that is not specifically linked to nuchal cords.
Question 2 of 5
A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?
Correct Answer: A
Rationale: The correct answer is A: Single palmar creases. This finding is associated with Down Syndrome, which requires further evaluation by the provider. Single palmar creases are a physical characteristic commonly seen in infants with Down Syndrome. Reporting this to the provider allows for early intervention and appropriate management.
Choices B, C, D, and E are incorrect because Down Syndrome (choice
B) is not a clinical finding to report but rather a condition associated with single palmar creases. Rust-stained urine (choice
C) may indicate hematuria but is not a common concern in newborns. Transient circumoral cyanosis (choice
D) is a common finding in newborns that usually resolves on its own. Subconjunctival hemorrhage (choice E) is also a common and benign finding in newborns.
Question 3 of 5
A nurse is assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect?
Correct Answer: C
Rationale: The correct answer is C: Uterine tenderness. Endometritis is an infection of the uterine lining, which causes inflammation and tenderness in the uterus. This finding is expected in a client with endometritis.
A: Temperature of 37.4°C is within normal range postpartum and not specific to endometritis.
B: WBC count of 9,000/mm3 is within normal range and may not be significantly elevated in endometritis.
D: Scant lochia may not be a specific finding for endometritis as lochia changes can vary postpartum.
Question 4 of 5
A nurse is admitting a client to the birthing unit who reports her contractions started 1 hr ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions?
Correct Answer: D
Rationale: The correct answer is D: Postpartum hemorrhage. The client being 80% effaced and 8 cm dilated indicates she is in active labor, not at risk for ectopic pregnancy (
A). Hyperemesis gravidarum (
B) is severe nausea and vomiting during pregnancy, unrelated to cervical dilation. Incompetent cervix (
C) is characterized by painless cervical dilation in the second trimester. Postpartum hemorrhage (
D) is a risk due to the advanced cervical dilation and effacement, making it more likely for excessive bleeding during and after delivery.
Question 5 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.