ATI RN Maternal Newborn 2023 II

Extract:

A nurse is caring for a client who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding.

Question 1 of 5

After calling for assistance and notifying the provider, which of the following actions should the nurse take next?

A. Cover the umbilical cord with a sterile saline saturated towel.B. Administer oxygen via nonrebreather mask at 8 L/min.C. Perform a vaginal examination by applying upward pressure on the presenting Ð´Ð¾Ñ€Ð¾Ð¶Ð½Ñ‹Ð¹ part.D. Initiate an infusion of IV fluids for the client.

Correct Answer: C

Rationale: The correct answer is C: Perform a vaginal examination by applying upward pressure on the presenting part. This action is crucial to assess the progress of labor, ensure proper fetal positioning, and determine if there are any complications such as cord prolapse. Administering oxygen (
B) or IV fluids (
D) may be important interventions but are not the immediate priority in this scenario. Covering the umbilical cord (
A) with a towel may increase the risk of infection.
Therefore, the key step is to perform a vaginal examination to gather essential information for appropriate decision-making.

Extract:

A nurse in a prenatal clinic is caring for a group of clients.

Question 2 of 5

The nurse should recognize that which of the following clients has a contraindication for a contraction stress test?

A. A client who had a previous stillbirthB. A client who has a previous classical incisionC. A client who has gestational diabetes mellitusD. A client who had a nonreactive nonstress test

Correct Answer: B

Rationale: The correct answer is B because a client with a previous classical incision (vertical uterine incision) is at risk for uterine rupture during a contraction stress test due to the weakened uterine wall. A uterine rupture can lead to severe complications for both the mother and the baby. Clients with previous classical incisions should not undergo contraction stress tests.

Choice A is incorrect because a previous stillbirth is not a contraindication for a contraction stress test.
Choice C is incorrect as gestational diabetes mellitus alone is not a contraindication for the test.
Choice D is also incorrect as a nonreactive nonstress test does not directly contraindicate a contraction stress test.

Extract:

A nurse is providing information about newborn security to the parents of a newborn.

Question 3 of 5

Which of the following instructions should the nurse provide?

A. Limit visitors to your immediate family.'B. Send the newborn to the nursery while you are sleeping.'C. Remove your newborn's electronic monitoring band for bathing.'D. Check identification badges of staff who enter your room.'

Correct Answer: D

Rationale: The correct answer is D. Checking identification badges of staff who enter the room is crucial for ensuring the safety and security of the newborn and the mother. By verifying the identity of the staff, the nurse can prevent unauthorized individuals from accessing the room and potentially harming the newborn or the mother. This practice also helps in maintaining a secure and controlled environment within the healthcare setting.

Choice A is incorrect because limiting visitors to immediate family may not address all potential risks to the newborn and mother.
Choice B is incorrect as sending the newborn to the nursery while the mother is sleeping may disrupt bonding and breastfeeding.
Choice C is incorrect as removing the electronic monitoring band can compromise the monitoring of the newborn's vital signs.

Extract:

A nurse is performing a nutritional assessment for a client during their first prenatal visit at 12 weeks of gestation.

Question 4 of 5

Which of the following findings indicates that the client should be referred to a registered dietician?

A. The client reports a 4 kg (10 lb) weight gain since their positive pregnancy test.B. The client reports that they eat prunes to help manage their constipation.C. The client reports that they take a multivitamin daily.D. The client reports that they are nauseous most mornings.

Correct Answer: A

Rationale: The correct answer is A because a 4 kg (10 lb) weight gain since a positive pregnancy test can indicate potential issues with nutrition during pregnancy, such as excessive weight gain or inadequate nutrient intake. This finding suggests the need for specialized dietary guidance from a registered dietitian.
Choice B is incorrect as eating prunes for constipation is a common dietary practice and does not necessarily require a dietician referral.
Choice C indicates the client is taking a multivitamin, which is generally a positive health behavior but does not alone warrant a dietitian referral.
Choice D of experiencing morning nausea is common in pregnancy and does not directly relate to needing dietitian intervention.

Extract:

A nurse is reviewing the prescriptions for a client who is pregnant and is taking digoxin.

Question 5 of 5

Which of the following actions should the nurse take to best evaluate the client's medication adherence?

A. Ask the client if they are taking the medication as prescribed.B. Determine the client's apical pulse rate.C. Check the client's serum medication level.D. Assess the client's kidney function.

Correct Answer: C

Rationale: The correct answer is C: Check the client's serum medication level. This action is the most direct and objective method to evaluate medication adherence. By measuring the actual concentration of the medication in the client's blood, the nurse can determine if the prescribed medication is being taken as directed. This method provides concrete evidence of adherence compared to just asking the client (
A), which may not always be reliable. Determining the apical pulse rate (
B) and assessing kidney function (
D) are important aspects of client care but are not directly related to evaluating medication adherence.

ATI RN Maternal Newborn 2023 II | Nurselytic

Nurselytic

ATI RN

ATI RN