ATI RN
ATI Maternal Newborn Proctored Exam Latest Update Questions
Extract:
Question 1 of 5
A labor and delivery nurse suspects that a client is in the transition stage of labor. Which information supports this conclusion? The client is:
Correct Answer: B
Rationale: The correct answer is B: irritable and needs frequent repetition of directions. This behavior is indicative of the transition stage of labor, which is the most intense phase characterized by strong contractions and nearing full dilation. The client's irritability and need for repeated directions suggest she is experiencing intense pain and discomfort, typical of this stage.
Incorrect choices:
A: Walking around and talking may occur in early labor but not indicative of transition.
C: Expelling feces and fetal head crowning indicate the pushing stage, not transition.
D: Reading a magazine and talking on the phone are unlikely behaviors during transition due to the intensity of contractions.
Question 2 of 5
During the postpartum period, a hospitalized client complains of discomfort related to her episiotomy. The nurse assigns the diagnosis of 'pain related to perineal sutures.' Which nursing intervention is most appropriate during the first 24 hours following an episiotomy?
Correct Answer: D
Rationale: The correct answer is D: Apply ice packs to the perineum. This intervention helps reduce swelling, inflammation, and provides pain relief by numbing the area. Ice constricts blood vessels, reducing blood flow to the area, which can minimize pain and discomfort. Ice packs should be applied for short periods, typically 20 minutes on and 20 minutes off, to prevent skin damage. This intervention is most appropriate during the first 24 hours post-episiotomy as it helps manage acute pain and promotes healing.
Other choices are incorrect:
A: Using petroleum jelly can increase the risk of infection and hinder wound healing.
B: Kegel exercises focus on pelvic floor muscle strength and do not directly address pain related to perineal sutures.
C: Sitz baths are beneficial for promoting healing but may not provide immediate pain relief like ice packs.
Question 3 of 5
A nurse is assessing a newborn following a circumcision. Which of the following should the nurse identify as an indication that the newborn is experiencing pain?
Correct Answer: B
Rationale: The correct answer is B: Chin quivering. This is because chin quivering is a common sign of pain in newborns following circumcision. It indicates discomfort or distress. Decreased heart rate (
A), pinpoint pupils (
C), and slowed respirations (
D) are not typical indicators of pain in newborns. A decrease in heart rate and slowed respirations may suggest relaxation or a calming response, while pinpoint pupils may indicate a different issue such as opioid overdose.
Question 4 of 5
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Report the client’s condition to the local health department. This is important to ensure proper monitoring, contact tracing, and support for the client and public health. Administering penicillin G (choice
A) is not indicated for HIV positive individuals. Instructing the client to schedule an annual pelvic exam (choice
B) is not a priority in this situation. Starting medication for HIV after delivery (choice
C) may delay necessary treatment for the client.
Therefore, reporting the client's condition to the local health department is the most appropriate action to ensure comprehensive care and public health measures.
Question 5 of 5
Which of the following physical manifestations of a client with anorexia nervosa best indicates compliance with the treatment plan of care?
Correct Answer: A
Rationale: The correct answer is A: "A weekly weight gain of 1 kg (2.2 lb)". In anorexia nervosa, weight restoration is a crucial goal. A weekly weight gain of 1 kg indicates compliance with the treatment plan as it shows the client is consuming an adequate amount of calories and nutrients. This is essential for reversing the physical effects of malnutrition.
Choices B, C, and D are incorrect because soft bowel movements, return of regular menstrual periods, and improvement of oral mucosa, while important indicators of health, do not directly reflect compliance with the treatment plan in anorexia nervosa. Weight gain is a key marker of nutritional rehabilitation and recovery in individuals with anorexia nervosa.