ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 of 5
A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?
Correct Answer: A
Rationale: The correct answer is A: Single palmar creases. This finding may indicate a chromosomal abnormality like Down Syndrome. The nurse should report this to the provider for further evaluation and genetic testing. Single palmar creases are not typically seen in healthy newborns.
Choices B, C, D, and E are normal findings in newborns. Down Syndrome is associated with multiple physical and developmental characteristics, not just single palmar creases. Rust-stained urine may be from uric acid crystals, which is common in newborns. Transient circumoral cyanosis and subconjunctival hemorrhage can occur due to normal physiological processes during birth and usually resolve on their own without intervention.
Question 2 of 5
A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effects should the nurse include?
Correct Answer: A
Rationale: The correct answer is A: Breast tenderness. Clomiphene citrate is a medication commonly used to treat infertility by inducing ovulation. Breast tenderness is a common side effect due to the hormonal changes caused by the medication. This occurs because clomiphene citrate can increase estrogen levels, leading to breast discomfort. Tinnitus (
B), urinary frequency (
C), and chills (
D) are not typically associated with clomiphene citrate use. Tinnitus is more commonly linked to ototoxic medications, urinary frequency may be seen with diuretics, and chills are often indicative of an infection or allergic reaction.
Therefore, breast tenderness is the most relevant adverse effect to include in the teaching for a client experiencing infertility and taking clomiphene citrate.
Question 3 of 5
A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client’s history should the nurse recognize as a contraindication to oral contraceptives? (Select all that apply.)
Correct Answer: A, B, D
Rationale: The correct answers are A, B, and D. Cholecystitis is a contraindication due to increased risk of gallbladder disease. Hypertension is a contraindication as it can be exacerbated by oral contraceptives. Migraine headaches with aura are a contraindication due to increased risk of stroke. Human papillomavirus is not a contraindication.
Question 4 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 typically spread through direct contact with an infected person or contaminated surfaces.
Therefore, the nurse should implement contact precautions to prevent the transmission of the bacteria. This includes wearing gloves and gowns when entering the client's room, ensuring proper hand hygiene, and using dedicated patient care equipment. Droplet precautions (choice
A) are used for pathogens spread via respiratory droplets, such as influenza. Protective environment (choice
C) is used for immunocompromised clients to protect them from environmental pathogens. Airborne precautions (choice
D) are for pathogens that remain suspended in the air, like tuberculosis.
Question 5 of 5
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
Correct Answer: C
Rationale:
Correct Answer: C - Remove all clothing from the newborn except the diaper.
Rationale: Phototherapy involves exposing the newborn's skin to light to breakdown excess bilirubin.
To maximize the effectiveness of phototherapy, the newborn should have as much skin exposed to the light as possible. Removing all clothing except the diaper ensures that the most surface area is exposed to the light, improving bilirubin breakdown.
Summary of other choices:
A: Feeding water is not directly related to phototherapy for hyperbilirubinemia.
B: Applying lotion does not aid in the effectiveness of phototherapy.
D: Discontinuing therapy due to a rash may compromise the treatment of hyperbilirubinemia.