ATI RN
RN ATI Maternal Newborn 2023 with NGN Questions
Extract:
Question 1 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 within the first 24 hours can be a sign of pathologic hyperbilirubinemia, which can be harmful. The nurse should report this to the provider promptly for further evaluation and management. Acrocyanosis (
A) is a common finding in newborns due to immature circulation and is not concerning. Transient strabismus (
B) is a common finding that typically resolves on its own and does not require immediate intervention. Caput succedaneum (
D) is swelling on the scalp that usually resolves without treatment.
Question 2 of 5
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?
Correct Answer: B
Rationale: The correct answer is B: Chin quivering. Chin quivering is a common indicator of pain in newborns as they are unable to verbally express discomfort. It is a physical sign of distress often observed during painful procedures like circumcision. Decreased heart rate (choice
A), pinpoint pupils (choice
C), and slowed respirations (choice
D) are not specific indicators of pain in newborns and can be influenced by various factors. In contrast, chin quivering is a more reliable and direct sign of pain in this context.
Question 3 of 5
A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
Correct Answer: B
Rationale: The correct answer is B: Temperature. Amniotomy involves breaking the amniotic sac, increasing the risk of infection. Monitoring the client's temperature is crucial to detect early signs of infection, such as fever. Maintaining a normal temperature is essential to prevent maternal and fetal complications. O2 saturation, blood pressure, and urinary output are important assessments but do not take priority over monitoring the client's temperature post-amniotomy.
Extract:
“A nurse on an antepartum unit is caring for a client.
Exhibit1:
Nurses' Notes 0900:Client reports a small amount of bright red blood in their underwear upon
awakening. Client denies contractions or abdominal pain. External fetal monitor applied.
0930:Client passed large amount of bright red blood from vagina.
Denies pain Uterine tone soft and nontender to palpation.
contraction pattern, no contractions noted.
Fetal heart rate pattern: Fetal heart rate baseline 135/min.
Moderate variability. No decelerations noted.
Exhibit2:
Vital Signs 0900: Temperature 36.2°C (97.2° F) Pulse rate 78/min Respiratory rate 20/min Blood pressure
112/64 mm Hg Fetal heart rate 132/min Pulse rate 82/min Blood pressure 116/60 mm Hg Fetal heart
rate 160/min
Exhibit3:
Medical History. G4P3 30 weeks gestation Previous pregnancies delivered via cesarean section
Question 4 of 5
Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify it the intervention is indicated or contraindicated for the client.
| Potential Nursing Action | Indicated | Contraindicated | |
|---|---|---|---|
| Insert a large bore intravenous catheter. | |||
| Assess cervical dilation. | |||
| Weigh perineal pads. | |||
| Administer methotrexate. |
Correct Answer: A, C
Rationale: , (B, 0, 1, 0), (C, 1, 0, 1), (D, 0, 0, 0)
- A: Inserting a large bore IV catheter is indicated for emergency situations to provide rapid fluid replacement or administer medications.
- B: Assessing cervical dilation is not indicated unless specifically related to the client's condition, not a routine nursing action.
- C: Weighing perineal pads is indicated to monitor postpartum hemorrhage by measuring blood loss.
- D: Administering methotrexate is contraindicated in the absence of a specific indication or prescription for the client.
Extract:
A nurse is caring for a newborn who is 48 hr old.
Exhibit 1
Vital Signs
Day 2, 0900:
Heart rate 174/min
Respiratory rate 88/min
Temperature 36.1° C (97.0° F)
Oxygen saturation 97% on room air
Exhibit 2
Diagnostic Results
Day 1, 0800: Newborn results
Blood type: A+
Urine toxicology screen: positive marijuana
Day 2, 0800: Newborn results
Total bilirubin 10 mg/dL (1.0 to 12.0 mg/dL)
Day 2, 0915:
Blood glucose: 38 mg/dL (expected value greater than 40 to 45
gm/dL
Exhibit 3
Nurses Notes
Day 2, 0900:
Newborn awake, alert, and crying. Loosely wrapped in one
blanket. Mild tremors noted. Yellow discoloration of mucus
membranes and sclera noted. Respirations 88/min, no
retractions, grunting, or nasal flaring noted. Diaper changed for
small amount of urine and transitional stool. Exhibit 4
Medical History
Apgars: 7 at 1 min and 8 at 5 min of age
Birth weight: 3,515 g (7 lb 12 oz)
Maternal blood type: O+
Uncomplicated pregnancy. Maternal use of marijuana during
pregnancy
Client who gave birth plans to breastfeed.
Question 5 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Correct Answer:
Rationale: Action to Take: A, B; Potential Condition: B; Parameter to Monitor: C, E.
Rationale: The correct answer is to place newborn skin to skin on birthing parent's chest and encourage breastfeeding to address potential condition of Cold stress. Parameters to monitor are temperature and bilirubin level. Skin-to-skin contact and breastfeeding help regulate newborn's temperature and decrease risk of hypothermia. Cold stress can lead to increased bilirubin levels, so monitoring temperature and bilirubin levels will help assess the baby's progress. Incorrect options: Option A focuses on phototherapy and neonatal abstinence system scoring, which are not indicated for cold stress. Option C includes stool output and lung sounds, which are not relevant for assessing cold stress.