ATI LPN
ATI Maternal Newborn Proctored Questions
Question 1 of 9
A client reports unrelieved episiotomy pain 8 hours following a vaginal birth. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Apply an ice pack to the affected area. Ice helps reduce inflammation and numb the pain, providing relief for the client. Step 1: Ice constricts blood vessels, reducing swelling and pain. Step 2: Ice numbs the area, providing immediate relief. Step 3: Ice is recommended for acute pain management. Summary: B (warm sitz bath) may increase blood flow and exacerbate swelling. C (antiseptic solution) is not indicated for pain relief. D (hot pack) may worsen inflammation and pain.
Question 2 of 9
A healthcare provider is preparing to administer vitamin K by IM injection to a newborn. The medication should be administered into which of the following muscles?
Correct Answer: A
Rationale: The correct answer is A: Vastus lateralis. This muscle is the preferred site for IM injections in newborns due to its large muscle mass and minimal risk of damage to nerves and blood vessels. Administering vitamin K in the vastus lateralis ensures proper absorption and distribution of the medication. Ventrogluteal and dorsogluteal sites are not recommended for newborns due to the risk of sciatic nerve damage and limited muscle mass. The deltoid muscle is typically used for older children and adults, not newborns.
Question 3 of 9
During the admission assessment of a newborn, which anatomical landmark should be used for measuring the newborn's chest circumference?
Correct Answer: B
Rationale: The correct answer is B: Nipple line. This landmark is used for measuring newborn chest circumference as it ensures consistency in measurement and is a reliable reference point. The nipple line is anatomically consistent and easily identifiable, making it the ideal landmark for accurate measurements. Rationale: A: Sternal notch is not recommended for chest circumference measurement in newborns as it is not a consistent landmark and may vary among individuals. C: Xiphoid process is not suitable for chest circumference measurement as it is located at the lower end of the sternum and not commonly used for this purpose. D: Fifth intercostal space is not a recommended landmark for chest circumference measurement in newborns as it is not as reliable and consistent as the nipple line.
Question 4 of 9
A client is being cared for 2 hours after a spontaneous vaginal birth and has saturated two perineal pads with blood in a 30-minute period. Which of the following is the priority nursing intervention at this time?
Correct Answer: A
Rationale: The correct answer is A: Palpate the client's uterine fundus. Palpating the uterine fundus is crucial to assess for uterine atony, a common cause of postpartum hemorrhage. If the fundus is boggy or deviated, it indicates uterine atony and immediate interventions are needed. B: Assisting the client to a bedpan to urinate is important, but addressing the potential cause of excessive bleeding takes precedence. C: Administering oxytocic medication may be necessary to help stimulate uterine contractions, but assessing the fundus comes first to determine the underlying cause of bleeding. D: Increasing fluid intake is not the priority in this situation. Palpating the fundus and addressing potential hemorrhage are the immediate concerns.
Question 5 of 9
A client in active labor has 7 cm of cervical dilation, 100% effacement, and the fetus at 1+ station. The client's amniotic membranes are intact, but she suddenly expresses the need to push. What should the nurse do?
Correct Answer: C
Rationale: Rationale: Option C, having the client pant during the next contractions, is the correct answer. At 7 cm dilation with a sudden urge to push, it indicates possible fetal descent. Panting can help prevent rapid descent and reducing the risk of cervical edema or injury. It allows time for the cervix to dilate fully before pushing, preventing premature pushing and potential complications. Option A is not a priority at this stage. Option B is incorrect as observing for crowning might lead to premature pushing. Option D is not necessary as voiding is not the priority right now.
Question 6 of 9
A nurse in a prenatal clinic overhears a newly licensed nurse discussing conception with a client. Which of the following statements by the newly licensed nurse requires intervention by the nurse?
Correct Answer: B
Rationale: The correct answer is B because implantation actually occurs around 6-10 days after fertilization, not after conception. This is a critical distinction as conception refers to the union of sperm and egg to form a zygote, while fertilization specifically refers to the fusion of the genetic material. Therefore, the statement by the newly licensed nurse is inaccurate and requires intervention. A: Fertilization typically occurs in the outer third of the fallopian tube, making this statement correct. C: Sperm can indeed remain viable in the woman's reproductive tract for 2 to 3 days, indicating this statement is accurate. D: Bleeding or spotting can indeed accompany implantation, making this statement correct. In summary, choice B is incorrect because implantation occurs around 6-10 days after fertilization, not conception. Choices A, C, and D are all correct statements related to conception and fertilization.
Question 7 of 9
A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make?
Correct Answer: D
Rationale: The correct answer is D because urinary frequency is common in early pregnancy due to hormonal changes and pressure on the bladder from the growing uterus. This symptom typically improves by the end of the first trimester, as the uterus rises and reduces pressure on the bladder. Therefore, telling the client that it occurs during the first trimester and near the end of pregnancy is accurate. Choice A is incorrect because urinary frequency should not be ignored as it could be a sign of a urinary tract infection or other underlying issue. Choice B is incorrect because it inaccurately suggests that urinary frequency only lasts until the 12th week and implies that poor bladder tone is the sole factor influencing this symptom. Choice C is incorrect because while it is true that individual experiences can vary, there are general patterns and timelines for common pregnancy symptoms like urinary frequency.
Question 8 of 9
A client is being educated by a healthcare provider about the changes she should expect when planning to become pregnant. Identify the correct sequence of maternal changes. A. Amenorrhea B.Lightening C. Goodell's sign D. Quickening
Correct Answer: D
Rationale: The correct sequence of maternal changes when planning to become pregnant is A) Amenorrhea, C) Goodell's sign, D) Quickening, and B) Lightening. Amenorrhea is the absence of menstruation, indicating possible pregnancy. Goodell's sign is the softening of the cervix and vagina. Quickening is the first fetal movements felt by the mother. Lightening occurs as the baby drops lower into the pelvis. This sequence reflects the chronological order of physiological changes during pregnancy. Choices A, B, and C do not follow the correct sequence of maternal changes as outlined in pregnancy progression.
Question 9 of 9
A client reports unrelieved episiotomy pain 8 hours following a vaginal birth. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Apply an ice pack to the affected area. Ice helps reduce inflammation and numb the pain, providing relief for the client. Step 1: Ice constricts blood vessels, reducing swelling and pain. Step 2: Ice numbs the area, providing immediate relief. Step 3: Ice is recommended for acute pain management. Summary: B (warm sitz bath) may increase blood flow and exacerbate swelling. C (antiseptic solution) is not indicated for pain relief. D (hot pack) may worsen inflammation and pain.