ATI RN
ATI RN Maternal Newborn Latest Update. Questions
Extract:
Question 1 of 5
A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Administer the injection into the vastus lateralis muscle. For newborns, the vastus lateralis muscle is the preferred site for intramuscular injections due to the larger muscle mass and reduced risk of nerve damage. This site also allows for proper absorption of the vaccine. Massaging the site vigorously (
B) can cause discomfort and is not recommended. Inserting the needle at a 45° angle (
C) may not reach the muscle mass, leading to improper absorption. Using a 21-gauge needle (
D) is too large for a newborn and may cause unnecessary pain and tissue damage.
Question 2 of 5
A nurse is collecting data from a client who is at 30 weeks of gestation. Which of the following findings should the nurse identify as a manifestation of pyelonephritis?
Correct Answer: B
Rationale: The correct answer is B: Flank pain. Pyelonephritis is an infection of the kidneys that can cause flank pain due to inflammation of the renal parenchyma. This pain is typically located on one or both sides of the lower back, just below the rib cage. Epigastric discomfort (
A) is more commonly associated with conditions like gastritis or pancreatitis. A temperature of 37.7°C (99.8°F) (
C) can indicate a mild fever, but it is not specific to pyelonephritis. Abdominal cramping (
D) is more likely to occur in conditions like gastroenteritis.
Question 3 of 5
A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Administer the injection into the vastus lateralis muscle. For newborns, the vastus lateralis muscle is the preferred site for intramuscular injections due to the larger muscle mass and reduced risk of nerve damage. This site also allows for proper absorption of the vaccine. Massaging the site vigorously (
B) can cause discomfort and is not recommended. Inserting the needle at a 45° angle (
C) may not reach the muscle mass, leading to improper absorption. Using a 21-gauge needle (
D) is too large for a newborn and may cause unnecessary pain and tissue damage.
Extract:
A nurse is caring for a client who is experiencing a postpartum hemorrhage and has a new prescription for misoprostol.
Exhibit 2: Medical History
Preeclampsia
Cesarean birth of viable twin male newborns
Question 4 of 5
The nurse is assessing the client 30 min later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
| Findings 30 min later | Unrelated to diagnosis | Indication Of potential improvement | Indication of Potential worsening condition |
|---|---|---|---|
| Fundus at level of umbilicus | |||
| Cloudy urine | |||
| Blood pressure 80/50 mm Hg | |||
| Moderate lochia rubra | |||
| Thready pulse | |||
| Fundus firm to palpation |
Correct Answer:
Rationale: - A, D, E are correct, B, C are incorrect)
Rationale: A - Fundus at level of umbilicus indicates proper uterine involution. D - Moderate lochia rubra is expected postpartum. E - Thready pulse may indicate hypovolemia, requiring intervention. B - Cloudy urine may indicate infection, not improvement. C - Low blood pressure may indicate hypovolemic shock, a worsening condition.
Extract:
Question 5 of 5
A nurse is providing discharge teaching to a client following tubal ligation. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: D
Rationale: The correct answer is D: Ovulation will remain the same. This indicates an understanding of tubal ligation, a procedure that blocks the fallopian tubes to prevent pregnancy but does not affect ovulation. Ovulation will still occur, but the egg will not be able to travel to the uterus for fertilization.
A: Premenstrual tension may still occur as tubal ligation does not affect hormonal changes associated with the menstrual cycle.
B: Menstrual period length is not directly impacted by tubal ligation.
C: Hormone replacements are not typically needed after tubal ligation unless there are other underlying hormonal issues.
In summary, understanding that ovulation remains the same post-tubal ligation is crucial for the client to grasp the implications of the procedure accurately.