ATI RN
ATI RN Maternal Newborn Latest Update. Questions
Extract:
Question 1 of 5
A nurse is providing teaching to a client who is at 35 weeks of gestation and has a prescription for an amniocentesis. Which of the following client statements indicates an understanding of the teaching?
Correct Answer: A
Rationale: The correct answer is A. Emptying the bladder before amniocentesis helps prevent injury to the bladder during the procedure. This statement shows understanding of the importance of bladder emptying for safety and accuracy.
B: Incorrect. The client is typically lying on their back during amniocentesis.
C: Incorrect. The client is awake during the procedure.
D: Incorrect. Fasting is not required for amniocentesis.
Question 2 of 5
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Initiate seizure precautions. Neonatal abstinence syndrome can result in neurological symptoms, including seizures. Initiating seizure precautions involves ensuring a safe environment, padding the crib, and closely monitoring the infant for any signs of seizure activity. Monitoring blood glucose every hour (
A) is not typically indicated for neonatal abstinence syndrome. Placing the infant on his back with legs extended (
B) is a standard safe sleep practice but is not specific to managing neonatal abstinence syndrome. Providing a stimulating environment (
D) can exacerbate symptoms of withdrawal and should be avoided.
Question 3 of 5
A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Administer the injection into the vastus lateralis muscle. For newborns, the vastus lateralis muscle is the preferred site for intramuscular injections due to its larger muscle mass and minimal nerve endings, reducing the risk of injury and increasing absorption. This site is recommended by healthcare guidelines for administering vaccines to infants to ensure proper absorption and effectiveness. The other choices are incorrect because vigorously massaging the site (
B) can cause pain and tissue damage, inserting the needle at a 45° angle (
C) may not reach the muscle and can cause subcutaneous injection, and using a 21-gauge needle (
D) is not specific to the site and age group, potentially causing discomfort and inadequate absorption.
Question 4 of 5
A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Administer 500 mL lactated Ringer’s IV bolus. This action is appropriate as the client is experiencing postpartum hemorrhage, which can lead to hypovolemic shock. Administering IV fluids helps increase circulating volume and stabilize the client's condition. The other choices are incorrect because:
A) Replacing the surgical dressing does not address the underlying issue of hemorrhage.
B) Evaluating urinary output is important but not the priority when the client is actively bleeding.
C) Applying an ice pack to the incision site is not indicated and may not address the hemorrhage. Overall, choice D is the most crucial intervention to address the immediate concern of postpartum hemorrhage.
Question 5 of 5
A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?
Correct Answer: D
Rationale: The correct answer is D: Jitteriness. Infants born to mothers with gestational diabetes are at risk for hypoglycemia due to the abrupt cessation of the maternal glucose supply post-birth. Jitteriness is a common manifestation of hypoglycemia in newborns, indicating the need for prompt intervention to prevent further complications. Abdominal distention (
A) is not typically associated with hypoglycemia. Petechiae (
B) are small red or purple spots on the skin caused by bleeding under the skin and are not directly related to hypoglycemia. Increased muscle tone (
C) is not a typical sign of hypoglycemia in newborns.