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. A uterus palpated to the right above the umbilicus in a postpartum client indicates a full bladder displacing the uterus. This can lead to uterine atony and increase the risk of postpartum hemorrhage. By assisting the client to empty their bladder, the nurse can help the uterus contract properly and prevent complications.
Other choices are incorrect:
A: Reassessing in 2 hours does not address the immediate issue of a full bladder causing uterine displacement.
B: Administering simethicone is used for gas relief and is not relevant in this situation.
D: Instructing the client to lie on their right side does not address the underlying issue of a full bladder.
In summary, emptying the bladder is crucial to prevent complications post-vaginal delivery, making it the most appropriate intervention in this scenario.
Question 2 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 16-hour-old newborn can indicate respiratory distress, which requires immediate attention. Retractions occur when the skin pulls in between the ribs or under the rib cage with each breath, suggesting difficulty breathing. This finding is crucial to report promptly to the provider to ensure the newborn receives appropriate intervention and support. The other choices are incorrect:
B) Acrocyanosis is a common finding in newborns and is due to immature circulation.
C) Overlapping suture lines are normal in newborns and typically resolve over time.
D) A head circumference of 33 cm is within the normal range for a newborn.
Question 3 of 5
A nurse is assessing a client who is postpartum following a cesarean birth. The client states, 'I feel like I have to urinate but I can’t go.' Which of the following actions should the nurse take?
Correct Answer: A
Rationale:
Rationale:
Choice A is correct because assisting the client to ambulate to the bathroom can help relieve pressure on the bladder and facilitate urination. Walking can also help stimulate bladder emptying. Inserting a urinary catheter (
Choice
B) is invasive and should be avoided unless necessary. Performing a bladder scan (
Choice
C) may be considered if the client continues to have difficulty urinating after ambulating. Administering a diuretic (
Choice
D) is not indicated as it may exacerbate the issue by increasing urine production without addressing the underlying cause.
Question 4 of 5
A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?
Correct Answer: A
Rationale: The correct answer is A: Oligohydramnios. Electronic fetal monitoring is used to assess the well-being of the fetus during pregnancy. Oligohydramnios, which is a low level of amniotic fluid, can indicate poor fetal perfusion and compromise, necessitating closer monitoring. Hyperemesis gravidarum (
B) is severe morning sickness and does not directly affect fetal well-being. Leukorrhea (
C) is normal vaginal discharge during pregnancy and does not require fetal monitoring. Periodic tingling of the fingers (
D) is unrelated to fetal assessment.
Question 5 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 12 hours after birth can indicate hyperbilirubinemia, which may require medical intervention to prevent complications such as kernicterus. Acrocyanosis (
A) is a common finding in newborns due to immature circulation. Transient strabismus (
B) is a temporary misalignment of the eyes. Caput succedaneum (
D) is localized swelling on a newborn's head from pressure during birth and resolves on its own.