ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake 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. In newborns, the vastus lateralis muscle is the preferred site for intramuscular injections due to its size and relatively lower risk of hitting nerves or blood vessels. This muscle is located on the anterior lateral aspect of the thigh and is recommended for vaccines in infants. Administering the hepatitis B vaccine in this muscle ensures proper absorption and effectiveness of the vaccine.
Choices B, C, and D are incorrect. Massaging the site vigorously can cause discomfort and potential tissue damage. Inserting the needle at a 45° angle may result in subcutaneous rather than intramuscular injection. Using a 21-gauge needle, though commonly used, may not be the most appropriate size for newborns and can cause unnecessary pain.
Question 2 of 5
A nurse is caring for a client who is in labor and reports increasing rectal pressure. They are experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that their cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?
Correct Answer: B
Rationale: The correct answer is B: Active phase of labor. At 9 cm dilation, the client is transitioning from the latent phase to the active phase. In the active phase, the cervix typically dilates from 6 to 10 cm. The client's contractions are close together and long-lasting, indicating active labor. Rectal pressure is common during the active phase as the baby descends further. The passive descent (
A) phase occurs later in labor when the cervix is fully dilated, and the client is ready to push. Early phase (
C) is characterized by slow cervical dilation from 0 to 6 cm. Descent (
D) phase is not a recognized phase of labor.
Question 3 of 5
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
Correct Answer: D
Rationale: The correct answer is D: Respiratory distress. Hypoglycemia in a newborn can lead to inadequate glucose supply to the brain, causing respiratory distress due to central nervous system depression. Hypertonia (choice
A) is typically seen in hypocalcemia. Increased feeding (choice
B) may be a compensatory mechanism to address hypoglycemia. Hyperthermia (choice
C) is not a common manifestation of hypoglycemia. It is important to monitor for signs of respiratory distress in a late preterm newborn to promptly address hypoglycemia.
Extract:
A nurse is caring for a newborn who is 48 hr old.
Exhibit 1
Vital Signs
Day 2, 0900:
Heart rate 174/min
Respiratory rate 88/min
Temperature 36.1° C (97.0° F)
Oxygen saturation 97% on room air
Exhibit 2
Diagnostic Results
Day 1, 0800: Newborn results
Blood type: A+
Urine toxicology screen: positive marijuana
Day 2, 0800: Newborn results
Total bilirubin 10 mg/dL (1.0 to 12.0 mg/dL)
Day 2, 0915:
Blood glucose: 38 mg/dL (expected value greater than 40 to 45 gm/dL)
Complete the diagram by dragging from the choices below to specify what condition the client is
most likely experiencing, 2 actions the nurse should take to address that condition, and 2
parameters the nurse should monitor to assess the client’s progress.
Question 4 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Correct Answer:
Rationale: Action to Take: A, B; Potential Condition: B; Parameter to Monitor: C, E.
Rationale:
1. The potential condition the client is most likely experiencing is Acute bilirubin encephalopathy .
2. The nurse should take the actions of placing the newborn skin to skin on the birthing parent's chest and encouraging breastfeeding to address this condition.
3. Parameters to monitor include monitoring temperature (to assess for hypothermia related to cold stress) and monitoring the bilirubin level (to assess for bilirubin encephalopathy progression).
Summary:
-
Choice A is incorrect as obtaining a prescription for arterial blood gases and planning phototherapy are not directly related to the potential condition.
-
Choice C is incorrect as monitoring stool output, lung sounds, and blood glucose level are not specific to the potential condition identified.
- It's essential to focus on actions and parameters directly related to the identified potential condition for effective client care.
Extract:
A nurse is assessing a postpartum client during a follow-up visit.
Exhibit 3 - Vital Signs
Time Vital Signs
0930 Temperature 37°C (98.6°F)
Pulse rate 78/min
Respiratory rate 12/min
Blood pressure 124/80 mm Hg
Pulse oximetry 100%
Question 5 of 5
The nurse is teaching the client about postpartum depression. The nurse should encourage the client to----------------- and ----------------- to help prevent postpartum depression.
Correct Answer: B,E
Rationale: The correct answers are B and E. Maintaining a strong support system is crucial for emotional well-being, as it provides the client with reassurance, understanding, and help in times of need. This can help prevent feelings of isolation and loneliness, common in postpartum depression. Additionally, exercising for at least 30 minutes per day can release endorphins, improve mood, and reduce stress, all of which can contribute to preventing postpartum depression.
Choices A, C, and D are important for overall health but do not specifically address the emotional and mental aspects that can lead to postpartum depression.