ATI RN
ATI RN Maternal Newborn Latest Update. Questions
Extract:
Question 1 of 5
A nurse is assessing a client who is 1 hr postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Massage the client's fundus. This is the first action the nurse should take because excessive vaginal bleeding postpartum could indicate uterine atony, which is a common cause of postpartum hemorrhage. Massaging the fundus helps stimulate uterine contractions, which can help control bleeding. This should be done before administering medications like oxytocin (
B) or providing oxygen (
D), as addressing the underlying cause is crucial. Emptying the bladder (
C) is important but comes after addressing the uterine atony.
Extract:
A nurse is caring for a client who is experiencing a postpartum hemorrhage and has a new prescription for misoprostol.
Exhibit 2: Medical History
Preeclampsia
Cesarean birth of viable twin male newborns
Question 2 of 5
The nurse is assessing the client 30 min later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
| Findings 30 min later | Unrelated to diagnosis | Indication Of potential improvement | Indication of Potential worsening condition |
|---|---|---|---|
| Fundus at level of umbilicus | |||
| Cloudy urine | |||
| Blood pressure 80/50 mm Hg | |||
| Moderate lochia rubra | |||
| Thready pulse | |||
| Fundus firm to palpation |
Correct Answer:
Rationale: - A, D, E are correct, B, C are incorrect)
Rationale: A - Fundus at level of umbilicus indicates proper uterine involution. D - Moderate lochia rubra is expected postpartum. E - Thready pulse may indicate hypovolemia, requiring intervention. B - Cloudy urine may indicate infection, not improvement. C - Low blood pressure may indicate hypovolemic shock, a worsening condition.
Extract:
Question 3 of 5
A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Excessive crying. Neonatal abstinence syndrome is characterized by withdrawal symptoms in newborns exposed to drugs in utero. Excessive crying is a common manifestation due to irritability and discomfort. Diminished deep tendon reflexes (choice
A) are not typically associated. Decreased muscle tone (choice
C) is more commonly seen in conditions like hypotonia. Absent Moro reflex (choice
D) is not typically part of neonatal abstinence syndrome.
Question 4 of 5
A nurse is caring for a newborn immediately following birth. For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?
Correct Answer: D
Rationale: The correct answer is D:
To facilitate bonding between the newborn and parent. Delaying the instillation of antibiotic ointment allows for uninterrupted bonding time between the newborn and parent, promoting attachment and emotional connection. This is a critical time for parent-infant bonding and should not be interrupted by unnecessary procedures.
Choice A is incorrect because delaying the ointment does not impact the identification of infection; newborns are routinely monitored for signs of infection regardless.
Choice B is incorrect as the weight of the newborn is not a factor in delaying the ointment.
Choice C is irrelevant as the mode of delivery does not affect the timing of ointment instillation.
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 spread through direct contact with an infected individual or contaminated surfaces. Initiating contact precautions involves wearing gloves and gowns when caring for the client to prevent transmission. Droplet precautions (
A) are for diseases spread through respiratory droplets, such as influenza. Protective environment (
C) is used for immunocompromised clients to protect them from outside pathogens. Airborne precautions (
D) are for diseases spread through the air, like tuberculosis.
Therefore, in this scenario, contact precautions are the most appropriate to prevent the spread of MRSA.