ATI RN
VATI Maternal Newborn Assessment Questions
Question 1 of 5
Positive signs of pregnancy
Correct Answer: B
Rationale: One of the positive signs of pregnancy is the active fetal movements palpable by the examiner. This occurs when the examiner is able to feel the movements of the fetus inside the uterus. This sign usually becomes noticeable in the second half of pregnancy and is a clear indication that the pregnancy is progressing normally. It is a reassuring sign for both the pregnant individual and the healthcare provider that the fetus is active and healthy.
Question 2 of 5
A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?
Correct Answer: A
Rationale: Late decelerations on the fetal monitor strip indicate uteroplacental insufficiency. These decelerations occur after the peak of a contraction, and the fetus may not receive enough oxygen-rich blood during contractions. Uteroplacental insufficiency can lead to fetal hypoxia and acidosis if not addressed promptly. It is important for the nurse to take appropriate steps to improve fetal oxygenation, such as repositioning the mother, administering oxygen, and adjusting IV fluids. If late decelerations persist, further interventions may be necessary to ensure the well-being of the fetus.
Question 3 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 4 of 5
A newborn has a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, temperature of 36C and a persisting oxygen saturation of <87%. The nurse interprets these findings as:
Correct Answer: D
Rationale: The newborn's presentation with a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, and persisting low oxygen saturation (<87%) are indicative of respiratory distress. These signs suggest that the newborn is having difficulty breathing and may not be getting enough oxygen into their system. Respiratory distress in newborns is a serious condition that requires immediate attention and intervention to support breathing and oxygenation. It is crucial for healthcare providers to recognize and address respiratory distress promptly to prevent further complications.
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.