ATI RN
RN ATI Maternal Newborn 2023 with NGN 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. Palpating the uterus above the umbilicus indicates uterine atony, which can be caused by a distended bladder pressing on the uterus. Emptying the bladder helps the uterus contract effectively, preventing postpartum hemorrhage.
Choice A is incorrect as immediate intervention is needed.
Choice B (administering simethicone) is irrelevant to the situation.
Choice D (instructing the client to lie on their right side) does not address the underlying issue.
Question 2 of 5
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
Correct Answer: C
Rationale: The correct answer is C: Jaundice. Jaundice in a newborn within the first 24 hours can be a sign of pathologic hyperbilirubinemia, which can be harmful. The nurse should report this to the provider promptly for further evaluation and management. Acrocyanosis (
A) is a common finding in newborns due to immature circulation and is not concerning. Transient strabismus (
B) is a common finding that typically resolves on its own and does not require immediate intervention. Caput succedaneum (
D) is swelling on the scalp that usually resolves without treatment.
Question 3 of 5
A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: A
Rationale: The correct answer is A. By stating "I will eat foods that taste good instead of balancing my meals," the client shows an understanding of the importance of listening to their body's cravings and preferences while still maintaining a balanced diet to manage hyperemesis gravidarum. This response acknowledges the need to prioritize enjoyment of food while ensuring adequate nutrition.
Incorrect choices:
B: Avoiding a snack before bed may not address the issue of balancing meals throughout the day.
C: Having a cup of hot tea with each meal is unrelated to the principles of balancing meals or addressing hyperemesis gravidarum.
D: Eliminating dairy products may lead to nutrient deficiencies unless alternative sources of calcium and other essential nutrients are included in the diet.
Question 4 of 5
A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Have calcium gluconate readily available. Magnesium sulfate IV can lead to magnesium toxicity, causing decreased neuromuscular activity, including respiratory depression. Calcium gluconate is the antidote for magnesium sulfate toxicity as it antagonizes the effects of magnesium on the neuromuscular system. Having it readily available can help in case of an emergency.
Choice A is incorrect as fluid intake should not be restricted in preeclampsia.
Choice C is incorrect as assessing deep tendon reflexes every 6 hours is not directly related to managing magnesium sulfate infusion.
Choice D is incorrect as monitoring intake and output every 4 hours is not specific to the management of magnesium sulfate infusion.
Question 5 of 5
A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority?
Correct Answer: B
Rationale: The correct answer is B. Epigastric pain in a pregnant woman at 34 weeks could indicate a serious condition like pre-eclampsia, which requires immediate attention to prevent complications for both the mother and the baby. Gestational diabetes with a fasting blood glucose level of 120 mg/dL, as in choice A, is concerning but can be managed with appropriate interventions and monitoring.
Choice C's client with an Hgb of 10.4 g/dL is below the normal range but not an immediate priority unless there are symptoms of severe anemia.
Choice D's client at 39 weeks with urinary symptoms may indicate a urinary tract infection, which is important but not as urgent as potential pre-eclampsia.