ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 of 5
A nurse is assessing a client who is 3 days postpartum. Which of the following findings should the nurse report to the provider?
Correct Answer: A
Rationale: The correct answer is A: Cool, clammy skin. This finding could indicate hypovolemic shock, a serious postpartum complication. The nurse should report this to the provider immediately for further evaluation and intervention to prevent deterioration. Moderate lochia serosa (
B) is expected 3 days postpartum. Heart rate of 89/min (
C) and BP of 120/70 mm Hg (
D) are within normal range for a postpartum client and do not require immediate reporting.
Question 2 of 5
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?
Correct Answer: A
Rationale:
Correct
Answer: A. Administer broad-spectrum antibiotics.
Rationale: Administering broad-spectrum antibiotics is essential to prevent infection in the newborn with a leaking myelomeningocele. The exposed spinal cord increases the risk of infection, which can lead to serious complications such as meningitis. Antibiotics can help prevent or treat any potential infections.
Incorrect
Choices:
B. Monitoring rectal temperature every 4 hours is not the priority in this situation. Infection prevention and management should take precedence.
C. Cleansing the site with povidone-iodine may not be appropriate as it can be irritating to the exposed spinal cord.
D. Surgical closure after 72 hours may be delayed if there is an infection present. Administering antibiotics is crucial before proceeding with surgical closure.
Question 3 of 5
A nurse is caring for a newborn who has jaundice and a new prescription for phototherapy. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Close the newborn's eyes before applying eyepatches. This is important to protect the newborn's eyes from exposure to the bright light used in phototherapy, which can cause damage if the eyes are left open. Closing the eyes with eyepatches ensures that the light therapy is safely administered without harming the eyes.
A: Providing glucose water is not relevant to managing jaundice with phototherapy.
B: Turning the newborn every 4 hours is important for preventing pressure ulcers, but it is not directly related to phototherapy.
C: Applying hydrating lotion is not necessary before phototherapy and may interfere with the treatment.
E, F, G: Not provided.
Question 4 of 5
A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?
Correct Answer: A
Rationale: The correct answer is A: "You should have your provider refit you for a new diaphragm." This is important because postpartum changes in the body can affect the fit of the diaphragm. A refitting ensures proper size and fit for effective contraception.
Choice B is incorrect because oil-based lubricants can damage latex diaphragms.
Choice C is incorrect as the diaphragm should be kept in place for at least 6-8 hours, not 4 hours, for effective contraception.
Choice D is incorrect as diaphragms should be stored dry, not in sterile water, to prevent damage.
Question 5 of 5
A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?
Correct Answer: D
Rationale: The correct answer is D: Third-degree perineal laceration. Using a suppository in a client with a third-degree perineal laceration can potentially worsen the injury and increase the risk of infection. The suppository insertion may cause trauma to the already compromised tissue, leading to further complications. It is crucial to avoid any interventions that can exacerbate the injury and hinder the healing process.
Choices A, B, and C are not contraindications to using a suppository. Vaginal candidiasis, abdominal distention, and afterpains do not directly impact the safety or effectiveness of using a suppository in this scenario.