ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 of 5
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
Correct Answer: C
Rationale: The correct answer is C: Assist the client to empty their bladder. The palpation of the uterus above the umbilicus indicates uterine atony, a potential complication post-vaginal delivery. A full bladder can displace the uterus further, exacerbating the issue. Emptying the bladder helps the uterus contract and prevents excessive bleeding. Reassessing the client in 2 hours (
A) delays necessary intervention. Administering simethicone (
B) is for gas relief and not relevant here. Instructing the client to lie on their right side (
D) does not address the root cause.
Question 2 of 5
A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position. Which of the following questions should the nurse ask to evaluate the effectiveness of this intervention?
Correct Answer: D
Rationale: The correct answer is D: "Has your back labor improved?" This question is relevant because the occipitoposterior position can cause intense back pain during labor. By asking if the back pain has improved, the nurse can assess the effectiveness of the hands-and-knees position in helping to alleviate this specific discomfort.
Choice A: "Does that lessen your suprapubic pain?" is incorrect because the hands-and-knees position is not specifically targeted at suprapubic pain.
Choice B: "Are you feeling relief from your pelvic pressure?" is incorrect because the hands-and-knees position is more effective for back pain relief rather than pelvic pressure.
Choice C: "Do your contractions feel further apart?" is incorrect because the position change may not directly affect the frequency of contractions.
In summary, the correct question (
D) focuses on the specific issue of back labor associated with occipitoposterior position, making it the most relevant evaluation of the intervention.
Question 3 of 5
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
Correct Answer: C
Rationale:
Correct Answer: C - Remove all clothing from the newborn except the diaper.
Rationale: Phototherapy involves exposing the newborn's skin to light to breakdown excess bilirubin.
To maximize the effectiveness of phototherapy, the newborn should have as much skin exposed to the light as possible. Removing all clothing except the diaper ensures that the most surface area is exposed to the light, improving bilirubin breakdown.
Summary of other choices:
A: Feeding water is not directly related to phototherapy for hyperbilirubinemia.
B: Applying lotion does not aid in the effectiveness of phototherapy.
D: Discontinuing therapy due to a rash may compromise the treatment of hyperbilirubinemia.
Question 4 of 5
A nurse is caring for a client who is to receive oxytocin to augment their labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
Correct Answer: A
Rationale: The correct answer is A: Late decelerations. Late decelerations indicate uteroplacental insufficiency, suggesting that the fetus is not receiving enough oxygen. Administering oxytocin in the presence of late decelerations could further compromise fetal oxygenation and lead to fetal distress. It is crucial to report this finding to the provider to ensure the safety of both the mother and the baby.
Choices B, C, and D are incorrect:
B: Moderate variability of the FHR is a reassuring sign indicating a healthy fetal status.
C: Cessation of uterine dilation may signal a potential issue but does not directly contraindicate the initiation of oxytocin.
D: Prolonged active phase of labor may necessitate oxytocin augmentation but does not contraindicate its initiation.
Question 5 of 5
A nurse is caring for a client who is at 36 weeks of gestation and has methicillin-resistant Staphylococcus aureus. Which of the following types of isolation precautions should the nurse initiate?
Correct Answer: B
Rationale: The correct answer is B: Contact precautions. Methicillin-resistant Staphylococcus aureus (MRS
A) is typically spread through direct contact with an infected person or contaminated surfaces.
Therefore, the nurse should implement contact precautions to prevent the transmission of the bacteria. This includes wearing gloves and gowns when entering the client's room, ensuring proper hand hygiene, and using dedicated patient care equipment. Droplet precautions (choice
A) are used for pathogens spread via respiratory droplets, such as influenza. Protective environment (choice
C) is used for immunocompromised clients to protect them from environmental pathogens. Airborne precautions (choice
D) are for pathogens that remain suspended in the air, like tuberculosis.