ATI RN
ATI RN Maternal Newborn level 3 Final Exam 2023 Questions
Extract:
Question 1 of 5
A nurse is assessing a client who is in preterm labor and has a new prescription or terbutaline 0.25 mg subcutaneous. For which of the following findings should the nurse Withhold the medication and Report to the provider?
Correct Answer: B
Rationale: The correct answer is B: Blood pressure 88/58 mmHg. This blood pressure reading indicates hypotension, which could be a potential side effect of terbutaline. Hypotension can worsen maternal and fetal perfusion, leading to adverse outcomes. The nurse should withhold the medication and report this finding to the provider immediately.
Choices A, C, and D are within normal limits and do not require withholding the medication. A fasting blood glucose of 75 mg/dL is normal, urinary output of 40 ml/hr is adequate, and a fetal heart rate of 120/min is also within the normal range for a preterm fetus.
Question 2 of 5
A nurse is preparing to perform a fundal massage for a postpartum client with hearing seeing uterine atony. In which order should the nurse plan to perform the following actions? (molded steps into the box on the right. Placing them in order of performance use all steps)
Correct Answer: A,B,C,D
Rationale:
Step 1 (
A): Asking the client to lie on her back with knees flexed allows for proper access to the fundus and facilitates the massage.
Step 2 (
B): Positioning one hand around the top of the client's uterus and the other just above the symphysis pubis helps in locating and stabilizing the fundus.
Step 3 (
C): Rotating the upper hand to massage the uterus while applying slight downward pressure helps in stimulating contractions and reducing uterine atony.
Step 4 (
D): Observing the client's perineum for clots and bleeding is important to assess postpartum hemorrhage.
Summary:
Choice E, F, and G are incorrect as they do not provide essential steps for performing a fundal massage. E: There is no action step here. F and G: These steps are not necessary before the primary steps of fundal massage.
Question 3 of 5
A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions Should the nurse include in the plan of care?
Correct Answer: B
Rationale: The correct answer is B: Bathe the newborn before initiating skin to skin contact. This is important to minimize the risk of HIV transmission from the mother to the newborn. Bathing the newborn helps to remove any potential blood or body fluids that may contain the virus. Initiating skin to skin contact without bathing the newborn first could increase the risk of transmission.
Choice A is incorrect because using a fetal scalp electrode during labor and delivery is unrelated to preventing HIV transmission.
Choice C is incorrect because instructing the client to stop taking antiretroviral medication at 32 weeks of gestation could harm both the mother and the baby by increasing the risk of HIV transmission.
Choice D is incorrect because administering pneumococcal immunization to the newborn within 4 hours following birth is not directly related to preventing HIV transmission.
In summary, bathing the newborn before initiating skin to skin contact is the most appropriate action to prevent HIV transmission in this scenario.
Question 4 of 5
A nurse is caring for a newborn Boys 6 hours old and has a bedside glucose meter reading of 65 mg / DL. The New Orleans mother has Type 2 diabetes mellitus. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Feed the newborn immediately. The newborn's glucose level of 65 mg/dL is within the normal range for a 6-hour-old infant. In this case, the nurse should initiate feeding as breastfeeding or formula feeding can help stabilize the newborn's blood sugar levels. Delaying feeding could lead to hypoglycemia. Administering dextrose IV (
Choice
A) is not necessary as the glucose level is not critically low. Obtaining a blood sample for serum glucose level (
Choice
B) is unnecessary at this point. Reassessing blood glucose prior to the next feeding (
Choice
C) may delay necessary action.
Question 5 of 5
A nurse is caring for a client who reports spontaneous rupture. The nurse observed fetal bradycardia in the FHR tracing and notices the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following should the nurse take next?
Correct Answer: D
Rationale: The correct answer is D. Cover the umbilical cord with a sterile saline-saturated towel. This action helps prevent cord compression and protects the cord from drying out, reducing the risk of infection. It also helps maintain blood flow to the fetus.
A: Initiating IV fluids is not the priority in this situation.
B: Performing a vaginal examination could worsen the situation by causing further cord compression.
C: Administering oxygen is important but should not be the first action in this scenario.
In summary, covering the umbilical cord with a sterile saline-saturated towel is crucial to prevent complications and maintain fetal well-being.