ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
A nurse is caring for a client who is pregnant in an antepartum clinic.
Vital Signs
0900:
Temperature 36.6°C (97.9°F)
Heart rate 88/min
Respiratory rate 18/min
Blood pressure 130/70 mm Hg
Oxygen saturation 97% on room air
1000:
Heart rate 76/min
Respiratory rate 20/min
Blood pressure 138/68 mm Hg
Oxygen saturation 98% on room air
Question 1 of 5
Which of the following findings should the nurse report to the provider?Select the 3 findings that should be reported.
Correct Answer: A,B,D
Rationale: The correct answers to report to the provider are A, B, and D.
A: Uterine contractions - Significant contractions could indicate preterm labor.
B: Fetal heart rate - Abnormal fetal heart rate can indicate fetal distress.
D: Vaginal examination - Risk of infection or cervical changes need provider evaluation.
C: Gestational age - Routine information, not typically requiring immediate provider notification.
E: Maternal blood pressure - Important but not typically urgent unless severely abnormal.
Extract:
A nurse is caring for a newborn who is 70 hr old. Exhibit 1
Medical History
Newborn delivered by repeat cesarean birth at 40 weeks of gestation.
Birth weight 3,515 g (7 lb 12 oz)
Apgar scores 8 at 1 min and 9 at 5 min
Maternal history of methadone use during pregnancy.
Exhibit 2
Vital Signs
0700:
Heart rate 156/min
Respiratory rate 58/min
Temperature 37.2° C (98.9° F)
Oxygen saturation 98% on room air
1100:
Heart rate 160/min
Respiratory rate 60/min
Temperature 37.3° C (99.2° F)
Oxygen saturation 96% on room air
Exhibit 3
Physical Examination
1100:
Newborn is inconsolable with a high-pitched cry. Newborn sucks vigorously on pacifier but
breastfeeds poorly. Respirations unlabored. Lungs sound clear on auscultation. Increased muscle
tone with moderate to severe tremors when disturbed. Hyperactive Moro reflex noted. Several
loose stools today.
Exhibit 4
Diagnostic Results
Maternal urine toxicology screen positive for opiates (negative)
Newborn urine toxicology screen positive for opiates (negative)
Question 2 of 5
Which of the following findings should the nurse report to the provider? Select all that apply.
Correct Answer: C,D
Rationale: The nurse should report central nervous system (CNS) and gastrointestinal (GI) findings to the provider because changes in these systems can indicate serious health issues. CNS findings may suggest neurological problems, while GI findings could indicate digestive issues or potential complications. Reporting these findings promptly allows the provider to assess the patient's condition thoroughly and intervene if necessary. Respiratory and oxygen saturation findings are important but may not always require immediate intervention. Other choices are not directly related to critical health concerns that need urgent attention.
Extract:
A nurse is caring for a newborn who is 48 hr old.
Exhibit 1
Vital Signs
Day 2, 0900:
Heart rate 174/min
Respiratory rate 88/min
Temperature 36.1° C (97.0° F)
Oxygen saturation 97% on room air
Exhibit 2
Diagnostic Results
Day 1, 0800: Newborn results
Blood type: A+
Urine toxicology screen: positive marijuana
Day 2, 0800: Newborn results
Total bilirubin 10 mg/dL (1.0 to 12.0 mg/dL)
Day 2, 0915:
Blood glucose: 38 mg/dL (expected value greater than 40 to 45 gm/dL)
Complete the diagram by dragging from the choices below to specify what condition the client is
most likely experiencing, 2 actions the nurse should take to address that condition, and 2
parameters the nurse should monitor to assess the client’s progress.
Question 3 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Action to Take
Potential Condition
Parameter to Monitor
Correct Answer:
Rationale: Action to Take: A, B; Potential Condition: B; Parameter to Monitor: C, E. The correct answer is to place newborn skin to skin on birthing parent's chest (
A) to promote bonding and regulate temperature, and encourage breastfeeding (
B) for nutrition and immune benefits. The potential condition the client is most likely experiencing is Cold stress (
B), indicated by the need for phototherapy. The nurse should monitor Temperature (
C) for signs of hypothermia and Bilirubin level (E) to assess jaundice severity. These interventions and parameters address the client's most likely condition and provide comprehensive care.
Extract:
A nurse in a clinic is caring for a 16-year-old adolescent.
Provider Prescriptions
1300:
Standing prescriptions for clients who present with abdominal pain:
Obtain laboratory tests:
Urinalysis
Cervical culture
C-reactive protein
Beta hCG
Question 4 of 5
Which of the following findings should the nurse report to the provider? (Select all that apply.)
Correct Answer: A,B,D,E,F
Rationale: The correct findings to report to the provider are A, B, D, E, and F. A - Abdominal assessment is crucial as it can indicate underlying issues. B - Vaginal discharge can be a sign of infection or other gynecological problems. D - Temperature abnormalities can signal infection or systemic issues. E - Dyspareunia (painful intercourse) may indicate underlying conditions. F - Condom usage is important for assessing safe sex practices. These findings are relevant for the provider to assess and potentially address any health concerns.
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 5 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: The correct answers to report to the provider are A, B, C, and G. A Coombs test result should be reported as it indicates potential hemolytic anemia. Mucous membrane assessment is crucial for hydration status and oxygenation. Intake and output levels are key indicators of kidney function and hydration status. Sclera color can indicate liver function or anemia.
Choices D, E, and F are important assessments but do not typically require immediate reporting unless they are outside of normal ranges and affecting the patient's condition.