A full-term newborn is being assessed by a nurse 15 minutes after birth. Which of the following findings requires intervention by the nurse?

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Maternal Newborn ATI Proctored Exam Questions

Question 1 of 5

A full-term newborn is being assessed by a nurse 15 minutes after birth. Which of the following findings requires intervention by the nurse?

Correct Answer: B

Rationale: Correct Answer: B (Respiratory rate 18/min) Rationale: A normal respiratory rate for a newborn is 30-60 breaths/min. A rate of 18/min is below the normal range, indicating potential respiratory distress requiring immediate intervention to ensure adequate oxygenation. Summary of other choices: A: Heart rate 168/min - Normal range for a newborn is 120-160/min. C: Tremors - Common in newborns due to immature nervous system, usually self-resolving. D: Fine crackles - May be present due to residual amniotic fluid and typically resolve without intervention.

Question 2 of 5

What is the most appropriate statement for a nurse to make to a client who has recently experienced a perinatal death?

Correct Answer: B

Rationale: The correct answer is B: "I'm sad for you." This response shows empathy and acknowledges the client's feelings without making assumptions or providing false reassurance. It validates the client's emotions and offers support. Incorrect choices: A: This statement assumes the client's feelings and may not be comforting. C: This statement is insensitive and can cause unnecessary guilt or blame. D: While well-intentioned, this statement may not align with the client's beliefs and can be dismissive of their grief.

Question 3 of 5

A client who is at 24 weeks of gestation and reports daily mild headaches is being cared for by a nurse. Which of the following instructions should the nurse include in the plan of care?

Correct Answer: B

Rationale: The correct answer is B: Recommend that the client perform conscious relaxation techniques daily. Headaches during pregnancy can be common due to hormonal changes and increased blood volume. The nurse should recommend non-pharmacological interventions like relaxation techniques to manage headaches safely without medication. Conscious relaxation techniques can help reduce stress and tension, potentially alleviating headaches. Ibuprofen (choice A) is not recommended during pregnancy due to potential harm to the fetus. Ginseng tea (choice C) is not safe for pregnant women as it may lead to complications. Soaking in a hot bath (choice D) with a water temperature of 105°F can raise the body temperature, which is not advised during pregnancy as it may harm the baby.

Question 4 of 5

A client in active labor reports back pain while being examined by a nurse who finds her to be 8 cm dilated, 100% effaced, -2 station, and in the occiput posterior position. What action should the nurse take?

Correct Answer: C

Rationale: The correct action is to assist the client to the hands and knees position. This position, also known as the all-fours position, can help alleviate back pain by encouraging the baby to rotate into a more favorable position for delivery. By being on hands and knees, gravity assists in the rotation of the baby. This position can also help relieve pressure on the mother's back and potentially facilitate a smoother labor progress. Effleurage (choice A) may provide comfort but doesn't address the positional issue. Placing the client in lithotomy position (choice B) can worsen the occiput posterior position. Applying a scalp electrode to the fetus (choice D) is not indicated in this scenario.

Question 5 of 5

A client who is at 22 weeks of gestation reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take?

Correct Answer: B

Rationale: The correct answer is B. The blotchy hyperpigmentation on the client's forehead is likely melasma, a common occurrence during pregnancy. This is due to hormonal changes causing increased melanin production. The nurse should educate the client that this is an expected occurrence during pregnancy and reassure her that it is usually temporary and will fade postpartum. Choice A (Tell the client to follow up with a dermatologist) is incorrect because dermatological consultation is not typically necessary for melasma during pregnancy. Choice C (Instruct the client to increase her intake of vitamin D) is incorrect because vitamin D deficiency is not typically associated with blotchy hyperpigmentation on the forehead during pregnancy. Choice D (Inform the client she might have an allergy to her skin care products) is incorrect because melasma is not caused by allergies to skincare products.

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