ATI RN
RN Maternal Nursing OB Newborn 2023 2024 Exam Questions
Extract:
A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hr old.
Physical Examination:
• Fontanels soft and flat
• Head molded with caput succedaneum
• Eyes symmetric, no discharge, sclera yellow
• Mucous membranes dry
• Abdomen soft and rounded, bowel sounds present x 4 quadrants
Question 1 of 5
Which of the following findings should the nurse report to the provider? (Select all that apply.)
Correct Answer: A,B,C,G
Rationale:
Extract:
A nurse is caring for a client who is at 33 weeks of gestation.
Diagnostic Results:
• Proteinuria 3+, straw-colored urine
• Platelet count 150,000/mm3 (150,000 to 400,000/mm3)
• BUN 18 mg/dL (10 to 20 mg/dL)
Question 2 of 5
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
| Findings 24 hr later | Sign of potential worsening condition | Sign of potential improvement | Unrelated to diagnosis |
|---|---|---|---|
| Hematuria | |||
| Proteinuria 2+ | |||
| Leukorrhea | |||
| Positive clonus | |||
| BUN 40 mg/dL | |||
| Platelet count 110,000/mm3 |
Correct Answer:
Rationale:
Extract:
A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
Medical History:
• Gravida 2 Para 2
• Cesarean birth
• Deep vein thrombosis with previous pregnancy
• Preeclampsia
• BMI of 32
Question 3 of 5
A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
| Findings 24 hr later | Indication of worsening condition | Indication of improving condition |
|---|---|---|
| Increased warmth in the extremity | ||
| Tachycardia | ||
| Leukocytosis | ||
| Scant lochia rubra | ||
| Decreased extremity edema |
Correct Answer:
Rationale:
Extract:
“A nurse on an antepartum unit is caring for a client.
Exhibit1:
Nurses' Notes 0900:Client reports a small amount of bright red blood in their underwear upon
awakening. Client denies contractions or abdominal pain. External fetal monitor applied.
0930:Client passed large amount of bright red blood from vagina.
Denies pain Uterine tone soft and nontender to palpation.
contraction pattern, no contractions noted.
Fetal heart rate pattern: Fetal heart rate baseline 135/min.
Moderate variability. No decelerations noted.
Exhibit2:
Vital Signs 0900: Temperature 36.2°C (97.2° F) Pulse rate 78/min Respiratory rate 20/min Blood pressure
112/64 mm Hg Fetal heart rate 132/min Pulse rate 82/min Blood pressure 116/60 mm Hg Fetal heart
rate 160/min
Exhibit3:
Medical History. G4P3 30 weeks gestation Previous pregnancies delivered via cesarean section
Question 4 of 5
Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify it the intervention is indicated or contraindicated for the client.
| Potential Nursing Action | Indicated | Contraindicated |
|---|---|---|
| Insert a large bore intravenous catheter. | ||
| Assess cervical dilation. | ||
| Weigh perineal pads. | ||
| Administer methotrexate. |
Correct Answer: A, C
Rationale: Inserting a large bore IV catheter is indicated to manage potential hemorrhage. Weighing perineal pads helps quantify blood loss. Assessing cervical dilation is contraindicated as it may exacerbate bleeding. Administering methotrexate is not relevant in this context.
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 5 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.
| Potential Nursing Action | Indicated | Contraindicated |
|---|---|---|
| Educate the parents to begin range of motion exercises on the affected arm after 1 week. | ||
| Assess for grasp reflex in the affected extremity. | ||
| Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt. | ||
| Instruct parents to limit physical handling for 2 weeks. |
Correct Answer:
Rationale: Educate the parents to begin range of motion exercises on the affected arm after 1 week is indicated. Passive ROM exercises of the arm are indicated to restore function of the extremity. The initiation of these exercises is delayed for approximately 1 week to prevent additional injury to the brachial plexus. Assess for grasp reflex in the affected extremity is indicated. With Erb-Duchenne paralysis, only the upper arm is affected. The function of the wrists and fingers should be unaffected; the nurse should assess for a palmar grasp reflex.Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt is indicated. Intermittent immobilization of the affected arm across the newborn's abdomen can be achieved by pinning the sleeve to the shirt.Instruct parents to limit physical handling for 2 weeks is contraindicated. Parents and guardians should participate in the physical care of their newborn to increase parental-infant attachment. Providing education and practice opportunities for the parents will decrease their fears of injuring the newborn and increase confidence and bonding.