ATI RN
VATI Maternal Newborn Assessment Questions
Question 1 of 5
The nurse is assessing a client at 36 weeks' gestation who reports swelling in the hands and face. What is the priority nursing action?
Correct Answer: A
Rationale: Swelling in the hands and face may indicate preeclampsia, requiring immediate blood pressure assessment.
Question 2 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 3 of 5
The nurse is monitoring a client during the second stage of labor. What finding indicates that birth is imminent?
Correct Answer: A
Rationale: The urge to push is a sign that the baby is descending, indicating that delivery is near.
Question 4 of 5
Multiparous patient admitted to labor unit with regular contractions 2 minutes apart and last 60 seconds. She reports labor began 6 hours ago and she had bloody show earlier this morning.The patient asks what stage of labor she is in
Correct Answer: B
Rationale: Based on the information provided, the patient is experiencing regular contractions 2 minutes apart lasting 60 seconds, and she had a bloody show earlier in the morning. These signs in a multiparous patient with 6 hours of labor indicate she is most likely in the transition phase of labor. The transition phase is characterized by intense contractions that are closer together, typically 2-3 minutes apart, and lasting longer, usually around 60-90 seconds. This stage signifies the progression towards the final stages of labor, leading up to the pushing stage and delivery. Therefore, the correct answer is B, Transition phase.
Question 5 of 5
What is the primary reason for administering Rh immunoglobulin to an Rh-negative mother after delivery?
Correct Answer: A
Rationale: Rh immunoglobulin prevents maternal sensitization to Rh-positive blood.