ATI RN
VATI Maternal Newborn Assessment Questions
Question 1 of 5
A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?
Correct Answer: A
Rationale: The priority nursing intervention in this situation is to palpate the client's uterine fundus. Saturating two perineal pads with blood in a 30-minute period after childbirth is indicative of excessive postpartum bleeding, also known as postpartum hemorrhage (PPH). Palpating the uterine fundus helps the nurse assess for uterine atony, a common cause of PPH. If the fundus is boggy or not firm, it indicates that the uterus is not contracting effectively to control bleeding, which can lead to further complications if not addressed promptly. Once uterine atony is identified, other interventions such as administering oxytocic medications can be initiated to help the uterus contract and control bleeding.
Question 2 of 5
A client in the first trimester reports nausea. What dietary recommendation should the nurse make?
Correct Answer: A
Rationale: Dry crackers before rising can help manage nausea by stabilizing blood sugar and reducing gastric discomfort.
Question 3 of 5
What is an advantage of the cervical cap over the diaphragm?
Correct Answer: A
Rationale: The advantage of the cervical cap over the diaphragm is that it typically has a lower failure rate in preventing pregnancy. Failure rates for contraceptive methods refer to the percentage of women who become pregnant within the first year of typical use. The cervical cap is generally associated with a lower failure rate compared to the diaphragm due to its snugger fit and ability to cover the cervix more effectively, resulting in better protection against sperm entering the uterus. This makes the cervical cap a more reliable option for women seeking effective contraception.
Question 4 of 5
During a nursing assessment the woman with rupture
Correct Answer: A
Rationale: In the scenario presented, the nurse's priority action should be to call for emergent medical assistance. A woman with a rupture during a nursing assessment could be experiencing a serious complication known as umbilical cord prolapse. This occurs when the umbilical cord slips through the cervix ahead of the baby, which can lead to compression of the cord and a serious decrease in oxygen supply to the baby. It is a medical emergency that requires immediate intervention by the healthcare team, which may include moving the mother into a knee-chest position or performing a cesarean section. Therefore, the priority action for the nurse is to ensure prompt medical intervention to protect the well-being of both the mother and the baby.
Question 5 of 5
Three hours after birth, a newborn of a mother with diabetes becomes jittery, has weak, high- pitched cry , and exhibits irregular respirations. The nurse recognizes that these signs are often associated with:
Correct Answer: C
Rationale: The signs described in the scenario - jitteriness, weak high-pitched cry, irregular respirations - are indicative of hypoglycemia in a newborn. Babies born to mothers with diabetes are at risk for hypoglycemia due to their exposure to high blood sugar levels in utero. After birth, when the baby is separated from the mother's blood supply, their own insulin production may lead to a sudden drop in blood glucose levels.