ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 of 5
A nurse is admitting a client to the labor and delivery unit when the client states, 'My water just broke.' Which of the following interventions is the nurse's priority?
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. This is the priority because the client's water breaking indicates a potential risk to the fetus, such as umbilical cord compression or prolapse. FHR monitoring helps assess fetal well-being and detect any signs of distress. Performing Nitrazine testing (
A) and checking cervical dilation (
C) can wait until after ensuring fetal safety. Assessing the fluid (
B) may provide some information but does not directly address the immediate concern for fetal well-being.
Question 2 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 crucial to ensure proper monitoring, contact tracing, and prevention of transmission to others. Reporting the client's HIV status is mandatory for public health purposes. Administering penicillin G (choice
A) is not relevant in this scenario. Instructing the client to schedule a pelvic exam (choice
B) and starting HIV medication after delivery (choice
C) are not immediate actions needed to address the client's HIV status.
Question 3 of 5
A nurse is caring for a client who is at 10 weeks of gestation. Which of the following findings should the nurse report to the provider?
Correct Answer: A
Rationale: The correct answer is A. Frequent vomiting with weight loss of 3 lb in 1 week is concerning as it may indicate hyperemesis gravidarum, a severe form of morning sickness that can lead to dehydration and malnutrition, posing risks to both the mother and fetus. This requires immediate medical attention to prevent complications.
B: Reports of mood swings are common in pregnancy due to hormonal changes and are not typically alarming.
C: Nosebleeds are common in pregnancy due to increased blood volume and hormonal changes, and occurring three times per week is not unusual.
D: Increased vaginal discharge is a common symptom of early pregnancy due to hormonal changes and increased blood flow to the pelvic area, which is typically not concerning.
Question 4 of 5
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
Correct Answer: A
Rationale: The correct answer is A: Substernal retractions. Substernal retractions in a newborn may indicate respiratory distress, which requires immediate attention from the provider to prevent further complications. Acrocyanosis (choice
B) is a common finding in newborns and is considered normal. Overlapping suture lines (choice
C) can be a result of molding during the birth process and typically resolve on their own. A head circumference of 33 cm (13 in) (choice
D) falls within the normal range for a newborn and does not require immediate reporting.
Question 5 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 late preterm newborn can lead to respiratory distress due to inadequate glucose supply to the brain, causing neurologic dysfunction. Hypertonia (choice
A) is more indicative of hypocalcemia. Increased feeding (choice
B) is not a typical manifestation of hypoglycemia. Hyperthermia (choice
C) is not directly related to hypoglycemia. In summary, respiratory distress is a key sign of hypoglycemia in a late preterm newborn, while the other choices are not specific indicators.