ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 of 5
A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
Correct Answer: B
Rationale: The correct answer is B: Temperature. During an amniotomy, there is an increased risk of infection due to the introduction of bacteria into the uterine cavity. Monitoring the client's temperature is crucial to detect any signs of infection promptly. A sudden spike in temperature could indicate chorioamnionitis, a serious infection that can harm both the mother and the baby. O2 saturation (
A), blood pressure (
C), and urinary output (
D) are important assessments but are not the priority in this situation. Monitoring O2 saturation is essential for fetal well-being but is not directly related to the amniotomy procedure. Blood pressure monitoring is significant for detecting any changes in maternal status, but infection assessment takes precedence in this case. Urinary output is essential for assessing hydration status and kidney function, but infection monitoring is more critical during an amniotomy.
Question 2 of 5
A nurse is observing a new guardian caring for their crying newborn who is bottle feeding. Which of the following actions by the guardian should the nurse recognize as a positive parenting behavior?
Correct Answer: A
Rationale: The correct answer is A because laying the newborn across the lap and gently swaying helps provide comfort and bonding, mimicking the soothing motion in the womb. This action promotes a secure attachment between the guardian and the newborn. Placing the newborn in a crib in a prone position (
B) is unsafe and increases the risk of sudden infant death syndrome (SIDS). Offering a pacifier dipped in formula (
C) can introduce unnecessary calories and increase the risk of overfeeding. Preparing a bottle of formula mixed with rice cereal (
D) is not appropriate for a newborn and can lead to digestive issues.
Question 3 of 5
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?
Correct Answer: B
Rationale: The correct answer is B: Perform Leopold maneuvers. Prior to applying an external transducer for fetal monitoring at 38 weeks of gestation, the nurse should perform Leopold maneuvers to determine the position of the fetus, fetal lie, presentation, and engagement. This helps in locating the fetal back and identifying the optimal placement for the transducer. Progression of dilatation and effacement (choice
A) is more relevant for labor assessment. Completing a sterile speculum exam (choice
C) is not necessary for fetal monitoring. Preparing a Nitrazine paper test (choice
D) is used to assess for rupture of membranes, not for applying an external transducer.
Question 4 of 5
A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority?
Correct Answer: B
Rationale: The correct answer is B: A client who is at 34 weeks of gestation and reports epigastric pain. This client should be identified as the priority because epigastric pain in pregnancy can be a sign of preeclampsia, a serious condition that requires immediate attention to prevent maternal and fetal complications. Preeclampsia is characterized by high blood pressure and protein in the urine, and it can lead to seizures (eclampsia) if not managed promptly. The other clients have issues that are important but not as urgent as potential preeclampsia. Client A's blood glucose level is elevated but not critically high, Client C's hemoglobin level is slightly low but not acutely life-threatening, and Client D's symptoms of urinary frequency and dysuria are common in late pregnancy and do not indicate a medical emergency.
Question 5 of 5
A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: C
Rationale:
Correct
Answer: C - "I will continue taking my insulin if I experience nausea and vomiting."
Rationale: Nausea and vomiting can lead to decreased food intake, which may cause a drop in blood glucose levels. Continuing to take insulin as prescribed is crucial to prevent hypoglycemia and maintain stable blood glucose levels for both the mother and the baby. This demonstrates the client's understanding of the importance of insulin therapy during pregnancy.
Summary of other choices:
A: Increasing insulin doses during the first trimester is not recommended without healthcare provider guidance as insulin needs may vary.
B: Exercising with blood glucose levels of 250 or greater can be dangerous and may lead to further hyperglycemia.
D: Consuming a bedtime snack high in refined sugar can cause blood glucose spikes, which is not recommended for diabetes management during pregnancy.