ATI RN
ATI Maternal Newborn Proctored Exam Latest Update Questions
Extract:
Question 1 of 5
A new mother is crying in her room. She tells the nurse that her new baby boy has enlarged breasts and she thinks that there is something wrong. How should the nurse respond?
Correct Answer: A
Rationale: The correct answer is A because enlarged breasts in newborn boys, known as breast buds or witch's milk, are a common and temporary occurrence due to hormonal changes from the mother. It typically resolves within a few weeks.
Choice B is unnecessary as the nurse already knows the cause.
Choice C is dismissive and lacks explanation.
Choice D is not the nurse's role; the nurse should provide education and reassurance first.
Question 2 of 5
A nurse is caring for a child with muscular dystrophy. Which of the following priority actions should the nurse include in the care of this child?
Correct Answer: D
Rationale: The correct answer is D: Have the child use an incentive spirometer and perform breathing exercises routinely. This is the priority action because children with muscular dystrophy are at risk for respiratory complications due to weakened respiratory muscles. Using an incentive spirometer and performing breathing exercises help maintain lung function and prevent respiratory infections.
A: Limiting physical activity and planning rest periods is important, but respiratory care takes precedence in muscular dystrophy.
B: Genetic counseling is important for family planning but does not directly impact the child's care.
C: Advising against vaccines can increase the risk of infections in a child with compromised respiratory function.
E, F, G: No information provided.
Question 3 of 5
The physician performs an amniotomy for a woman in labor. Which nursing action should follow the procedure?
Correct Answer: D
Rationale: The correct answer is D: Assess the fluid for color, odor, and amount. After an amniotomy, it is crucial to assess the amniotic fluid to ensure it is clear, odorless, and of the correct amount, which indicates normal fetal well-being. This assessment helps in identifying any potential issues such as meconium staining or infection. This nursing action directly follows the procedure and is essential for monitoring the health of both the mother and the baby. Checking capillary refill and oxygenation (
A) is important but not directly related to the amniotomy procedure. Monitoring maternal pulse and blood pressure (
B) is also important but not the immediate next step after amniotomy. Inspecting the perineum (
C) is necessary but not the priority following amniotomy.
Question 4 of 5
A woman enters the birthing center in active labor. She tells the nurse that her membranes ruptured 26 hours ago. The nurse immediately takes the client's vital signs. Which is the rationale for the nurse's actions?
Correct Answer: D
Rationale: The correct answer is D. Prolonged rupture of membranes increases the risk of infection. When the amniotic sac has been ruptured for an extended period, bacteria can enter the uterus, potentially leading to chorioamnionitis, a serious infection that can harm both the mother and the baby. The nurse is taking vital signs to monitor for signs of infection, such as an elevated temperature or an increased heart rate.
Choices A, B, and C are incorrect because they do not directly relate to the potential complications of prolonged rupture of membranes. Pulse rates may increase with infection, but not solely due to the length of time of ruptured membranes. Respiratory rates are not typically impacted by ruptured membranes, and transient hypertension is not a common complication of this situation.
Question 5 of 5
A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor?
Correct Answer: B
Rationale: The correct answer is B: "Have you noticed any bloody show or fluid coming from your vagina?" This question is important to assess for true labor because bloody show or fluid leakage can indicate ruptured membranes, which is a sign of true labor. This information helps differentiate between true labor and false labor. The other options are not directly related to distinguishing between true and false labor. Option A focuses on the timing of contractions, which is important but not specific to differentiating true from false labor. Option C inquires about the effect of movement on contractions, which is relevant but not as indicative as the presence of bloody show or fluid. Option D is about fetal movement, which is important for monitoring fetal well-being but does not help differentiate true labor from false labor.