ATI RN
ATI RN Maternal Newborn Latest Update. Questions
Extract:
A nurse is caring for a newborn.
Exhibit 1
Medical History
1600:
Apgar score 9 at 1 min and 9 at 5 min
Birth weight 4,706 g (10 lb 6 oz)
Gestational age 40 weeks
Difficult vaginal birth with shoulder dystocia. Exhibit 2
Nurses' Notes
1700:
Newborn is active and moves all extremities except for right arm. No spontaneous movement of
the right arm noted. Right arm remains at side during Moro reflex. Exhibit 3
Physical Examination
1830:
Absent Moro reflex noted in right arm.
Right shoulder and arm are internally rotated and adducted. Elbow extended. Forearm pronated
with wrist and fingers flexed. Diagnosis: Brachial plexus injury resulting in Erb-Duchenne (Erb's
palsy) paralysis.
Question 1 of 5
Which of the following actions should the nurse plan to implement? For each potential nursing action, click to specify if the intervention is indicated or contraindicated for the newborn.
Correct Answer:
Rationale:
Correct
Answer: B: Assess for grasp reflex in the affected extremity.
Rationale:
- Assessing for grasp reflex is indicated to evaluate neurologic function and muscle tone in the affected arm.
- This helps in determining the extent of impairment and guiding further interventions.
- Range of motion exercises (
A) may worsen the condition if performed too early.
- Immobilizing the arm (
C) may lead to joint stiffness and muscle atrophy.
- Limiting physical handling (
D) may hinder bonding and infant's development.
Extract:
A nurse in a clinic is caring for a 16-year-old adolescent.
Exhibit 1
History and Physical
Adolescent is sexually active with two current partners.
IUD in place
Reports not using condoms during sexual activity.
History of type 1 diabetes mellitus”
Question 2 of 5
Which of the following conditions should the nurse identify as being consistent with the adolescent's assessment findings? For each finding click to specify if the assessment findings are consistent with trichomoniasis, gonorrhea, or candidiasis. Each finding may support more than one disease process.
| Assessment Findings | Trichomoniasis | Gonorrhea | Candidiasis |
|---|---|---|---|
| Abdominal pain. | |||
| Greenish discharge. | |||
| Diabetes. | |||
| Pain on urination. | |||
| Absence of condom. |
Correct Answer: B, D
Rationale: The correct answer is B, D . Abdominal pain (
A) is not specific to any of the given conditions. Diabetes (
C) is not directly related to the assessment findings provided. Absence of condom (E) is not an assessment finding, but a behavior. Trichomoniasis is characterized by greenish discharge, and pain on urination can be a symptom of both gonorrhea and trichomoniasis.
Extract:
A nurse is caring for a client who is experiencing a postpartum hemorrhage and has a new prescription for misoprostol.
Exhibit 2: Medical History
Preeclampsia
Cesarean birth of viable twin male newborns
Question 3 of 5
The nurse is assessing the client 30 min later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
| Findings 30 min later | Unrelated to diagnosis | Indication Of potential improvement | Indication of Potential worsening condition |
|---|---|---|---|
| Fundus at level of umbilicus | |||
| Cloudy urine | |||
| Blood pressure 80/50 mm Hg | |||
| Moderate lochia rubra | |||
| Thready pulse | |||
| Fundus firm to palpation |
Correct Answer:
Rationale: The correct answer is . Fundus at the level of the umbilicus is an indication of potential improvement as it shows proper involution of the uterus. Cloudy urine is unrelated to the diagnosis and may indicate a urinary tract infection. Blood pressure of 80/50 mm Hg is an indication of potential worsening condition as it is considered hypotension. Moderate lochia rubra is an expected finding postpartum. Thready pulse is not included in the provided parameters, so it is not considered in the analysis.
Extract:
A nurse is assessing a postpartum client during a follow-up visit.
Exhibit 3 - Vital Signs
Time Vital Signs
0930 Temperature 37°C (98.6°F)
Pulse rate 78/min
Respiratory rate 12/min
Blood pressure 124/80 mm Hg
Pulse oximetry 100%
Question 4 of 5
The nurse is teaching the client about postpartum depression. The nurse should encourage the client to----------------- and ----------------- to help prevent postpartum depression.
Correct Answer:
Rationale:
Correct
Answer: C: Get adequate rest and sleep
Rationale:
1. Sleep deprivation is a common trigger for postpartum depression.
2. Adequate rest and sleep help regulate mood and reduce stress levels.
3. Lack of sleep can worsen depressive symptoms.
4. Rest and sleep are essential for physical and emotional recovery postpartum.
Summary:
A: Engaging in physical activity is beneficial but not directly linked to preventing postpartum depression.
B: While a support system is important, it may not solely prevent postpartum depression.
D: Eating a well-balanced diet is crucial for overall health but not the primary focus for preventing postpartum depression.
Extract:
A nurse is assessing a postpartum client who delivered vaginally 8 hr ago.
Exhibit 1 - Nurses' Notes: 0700
Breasts soft, nipples intact. Uterus palpated firm, midline, and at the level of the umbilicus.
Moderate amount of lochia rubra. Episiotomy site well approximated with mild edema and
ecchymosis. Client reports pain as 2 on a scale of 0 to 10. Able to void spontaneously; no bladder
distention. Deep tendon reflexes 1+. Peripheral edema 2+ in bilateral lower extremities.
Exhibit 2 - Nurses' Notes: 1100
Breasts soft, nipples intact. Uterus palpated soft with lateral deviation and 1 cm above the
umbilicus. Large amount of lochia rubra. Episiotomy site well approximated with mild edema
and ecchymosis. Client reports pain as 3 on a scale of 0 to 10. Deep tendon reflexes 1+.
Peripheral edema 2+ in bilateral lower extremities.
Question 5 of 5
Select the 3 findings that require immediate follow-up.
Correct Answer: A,B,C
Rationale: The correct answers are A, B, and C. A lateral deviation of the uterus could indicate a potential complication such as uterine inversion. Deep tendon reflexes being 1+ may suggest hyporeflexia, which could be a sign of neurological issues. A pain rating of 3 on a scale of 0 to 10, especially if increased, may indicate worsening pain that needs immediate attention.
Choices D, E, F, and G do not require immediate follow-up as they are not indicative of urgent conditions. Peripheral edema 2+ bilateral lower extremities may be normal postpartum. Uterine tone being soft is expected in the postpartum period. A large amount of lochia rubra is typically seen in the immediate postpartum period. Blood pressure of 136/86 mm Hg is within normal limits for a postpartum patient.