While caring for a newborn undergoing phototherapy to treat hyperbilirubinemia, which of the following actions should the nurse take?

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Maternal Newborn ATI Proctored Exam Questions

Question 1 of 9

While caring for a newborn undergoing phototherapy to treat hyperbilirubinemia, which of the following actions should the nurse take?

Correct Answer: A

Rationale: Correct Answer: A - Cover the newborn's eyes with an opaque eye mask while under the phototherapy light. Rationale: 1. Phototherapy light can cause eye damage, so covering the newborn's eyes with an opaque eye mask protects them. 2. Newborns' eyes are more sensitive to light, making eye protection crucial during phototherapy. Summary of Incorrect Choices: B: Keeping the newborn in a shirt won't protect the eyes from phototherapy light. C: Applying lotion can interfere with the effectiveness of phototherapy and may cause skin irritation. D: Turning and repositioning the newborn is important for comfort, but eye protection is the priority during phototherapy.

Question 2 of 9

A client is postpartum and has idiopathic thrombocytopenic purpura (ITP). Which of the following findings should the nurse expect?

Correct Answer: A

Rationale: Step 1: In idiopathic thrombocytopenic purpura (ITP), there is a decreased platelet count due to immune-mediated destruction of platelets. Step 2: This leads to an increased risk of bleeding and bruising in the postpartum client. Step 3: Other choices are incorrect because in ITP, there is no increase in ESR or WBC. Also, megakaryocytes may be normal or increased due to compensatory production.

Question 3 of 9

A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow.

Correct Answer: D

Rationale: The correct sequence for performing Leopold maneuvers is to first palpate the fundus to identify the fetal part (A), then determine the location of the fetal back (B), and finally palpate for the fetal part presenting at the inlet (C). Choosing option D (All of the Above) is correct because it encompasses all the necessary steps in the correct order to perform Leopold maneuvers effectively. Palpating the fundus helps identify the presenting part, determining the location of the fetal back provides information on the fetal lie, and palpating for the presenting part at the inlet helps confirm the position of the fetus. The other choices are incorrect because they do not provide the complete sequence required for performing Leopold maneuvers accurately.

Question 4 of 9

When developing an educational program for adolescents about nutrition during the third trimester of pregnancy, which of the following statements should be included?

Correct Answer: A

Rationale: The correct answer is A: Consume three to four servings of dairy each day. During the third trimester of pregnancy, calcium needs increase to support the baby's bone development. Dairy products are a rich source of calcium. Adolescents are still growing themselves, so adequate calcium intake is crucial for both the mother and baby. B: Increasing caloric intake by 600 to 700 calories is not specific to the third trimester and may lead to excessive weight gain, which can be harmful. C: Limiting sodium intake to less than 1 gram is not necessary during pregnancy, and some sodium is required for maintaining fluid balance. D: Increasing protein intake to 40 to 50 grams per day is important, but it is not specific to the third trimester and may vary based on individual needs.

Question 5 of 9

A client in labor requests epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?

Correct Answer: C

Rationale: The correct answer is C: Monitor the client's blood pressure every 5 minutes after the first dose of anesthetic solution. This is crucial as epidural anesthesia can cause hypotension, which can lead to maternal and fetal complications. Monitoring blood pressure every 5 minutes allows for early detection and intervention. A: Positioning the client supine for 30 minutes after the first dose of anesthetic solution can lead to hypotension due to decreased venous return, so this is incorrect. B: Administering dextrose 5% in water is not a standard practice after epidural anesthesia and does not address the risk of hypotension, so this is incorrect. D: Ensuring the client has been NPO for 4 hours before the procedure is important for general anesthesia but not specifically for epidural anesthesia, so this is incorrect.

Question 6 of 9

A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7-year-old child in accepting the new family member?

Correct Answer: C

Rationale: The correct answer is C: Obtain a gift from the newborn to present to the sibling. This suggestion helps foster acceptance and bonding between the siblings by creating a positive association and sense of reciprocity. It allows the 7-year-old to feel included and appreciated in the new family dynamic. Explanation of why the other choices are incorrect: A: Allowing the sibling to hold the newborn during a bath may not be safe or appropriate, and could potentially lead to accidents or discomfort for the newborn. B: Forcing physical affection like kissing may not be well-received by the sibling and could create negative feelings towards the newborn. D: Switching the sibling's room with the nursery could disrupt the sibling's sense of stability and security, potentially causing confusion and anxiety.

Question 7 of 9

A client at 42 weeks of gestation is having an ultrasound. For which of the following conditions should the nurse prepare for an amnioinfusion? (Select all that apply)

Correct Answer: A

Rationale: Rationale: A client at 42 weeks of gestation is at risk for oligohydramnios, which is associated with decreased amniotic fluid levels. Amnioinfusion can be used to increase amniotic fluid volume to prevent fetal cord compression and facilitate fetal movement during labor. Summary: - B: Hydramnios (excessive amniotic fluid) does not require amnioinfusion. - C: Fetal cord compression is a reason for amnioinfusion, not a condition to prepare for. - D: Polyhydramnios (excessive amniotic fluid) does not typically require amnioinfusion unless there are complicating factors.

Question 8 of 9

A healthcare provider in an antepartum clinic is collecting data from a client who has a TORCH infection. Which of the following findings should the healthcare provider expect? (Select all that apply)

Correct Answer: D

Rationale: The correct answer is D: Tender lymph nodes. In TORCH infections, which include Toxoplasmosis, Other (syphilis), Rubella, Cytomegalovirus, and Herpes simplex virus, tender lymph nodes are a common finding due to the body's immune response to the infection. Joint pain (choice A) is not typically associated with TORCH infections. Malaise (choice B) is a general feeling of discomfort and is not specific to TORCH infections. Rash (choice C) is also not a common finding in TORCH infections, making it an incorrect choice.

Question 9 of 9

During a nonstress test for a pregnant client, a nurse uses an acoustic vibration device. The client inquires about its purpose. Which response should the nurse provide?

Correct Answer: D

Rationale: The correct answer is D because the acoustic vibration device is used during a nonstress test to wake up a sleeping fetus, ensuring that the baby is active and responsive during the test. This helps to assess the baby's well-being and monitor its heart rate patterns. Choice A is incorrect as the device does not stimulate uterine contractions. Choice B is incorrect as it does not decrease the incidence of contractions. Choice C is incorrect as the device does not lull the fetus to sleep, but rather ensures the fetus is awake and moving during the test.

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