ATI Maternal Newborn Proctored Exam Latest Update -Nurselytic

Correct Answer: A

Rationale: The correct answer is A: Temperature 100.0 degrees F. This can be interpreted as normal post-vaginal delivery. The rationale is that a slight increase in temperature up to 100.4 degrees F is common due to the stress of labor and delivery, known as postpartal fever. It is considered normal as long as it doesn't exceed 100.4 degrees F.

Choices B, C, and D are incorrect as a blood pressure of 140/90 is elevated, respirations of 10 are too low, and a pulse of 90 is higher than expected after delivery. Monitoring these vital signs is crucial post-delivery to ensure the client's well-being.

Correct Answer: A

Rationale: The correct answer is A: Lack of required immunizations. Neglect refers to the failure to provide for a child's basic needs, including healthcare. Lack of immunizations puts the child at risk for preventable diseases, indicating neglect. Parental lack of education (
B) or being in a lower socioeconomic group (
C) do not directly indicate neglect. Faded clothing with large shoes (
D) may suggest financial difficulties but does not necessarily indicate neglect.

Correct Answer: B

Rationale: The correct answer is B: "FACES rating scale." This scale is commonly used to assess pain in children, including a 9-year-old. It uses facial expressions to help children express their pain levels. The nurse can ask the child to choose the face that best represents their pain. This scale is age-appropriate, easy to use, and effective in assessing pain in children who may have difficulty verbalizing their discomfort.
Other choices:
A: "Poker chip tool" - This tool involves assigning a numerical value to poker chips. It is not as commonly used or specific for pediatric pain assessment.
C: "Visual analog scale" - This scale requires the child to mark a point on a line to indicate pain intensity, which may be challenging for younger children.
D: "Numerical 1 to 10 rating scale" - While this scale is commonly used for pain assessment, it may be difficult for a 9-year-old to accurately quantify and verbalize their pain on a numerical

Correct Answer: A

Rationale: The correct answer is A, "Apical." This approach involves listening to the heart rate using a stethoscope placed over the apex of the heart. This method is most accurate for infants as it directly measures the heart's contractions. Radial (
B), ulna (
C), and brachial (
D) methods primarily measure peripheral pulses and may not accurately reflect the infant's heart rate due to potential delays in the transmission of the pulse from the heart to the peripheral arteries.
Therefore, apical auscultation is the preferred method for accurate heart rate measurement in infants.

Correct Answer: C

Rationale: The correct answer is C: Gravida 5, para 2. Gravida refers to the total number of pregnancies, including the current one. In this case, the client is currently pregnant for the 5th time. Para refers to the number of pregnancies that have reached viability (after 20 weeks). Since the client has a 4-year-old and a set of 1-year-old twins, she has had 2 pregnancies that reached viability.
Therefore, she is para 2.

Choices A and B are incorrect because they do not account for the client's previous pregnancies that reached viability.
Choice D is incorrect because it includes the current pregnancy in the para status, which is not accurate.