ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 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 sign of pain in newborns. It indicates discomfort and distress. Decreased heart rate (
A), pinpoint pupils (
C), and slowed respirations (
D) are not reliable indicators of pain in newborns. Heart rate may decrease as a response to pain, but it can also be affected by other factors. Pinpoint pupils are more indicative of drug use or neurological issues. Slowed respirations may be a sign of relaxation, not necessarily pain. Chin quivering, on the other hand, is a direct physical manifestation of pain and should be recognized by the nurse as a sign to address the newborn's discomfort.
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)
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.
Question 2 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:
1. The potential condition the client is most likely experiencing is Acute bilirubin encephalopathy .
2. The nurse should take the actions of placing the newborn skin to skin on the birthing parent's chest and encouraging breastfeeding to address this condition.
3. Parameters to monitor include monitoring temperature (to assess for hypothermia related to cold stress) and monitoring the bilirubin level (to assess for bilirubin encephalopathy progression).
Summary:
-
Choice A is incorrect as obtaining a prescription for arterial blood gases and planning phototherapy are not directly related to the potential condition.
-
Choice C is incorrect as monitoring stool output, lung sounds, and blood glucose level are not specific to the potential condition identified.
- It's essential to focus on actions and parameters directly related to the identified potential condition for effective client care.
Extract:
Question 3 of 5
A nurse is caring for a client who is at 10 weeks of gestation. Which of the following findings should the nurse report to the provider?
Correct Answer: A
Rationale: The correct answer is A because frequent vomiting with significant weight loss in a short period can indicate hyperemesis gravidarum, a severe form of nausea and vomiting in pregnancy. This condition can lead to dehydration and electrolyte imbalances, posing risks to both the mother and the fetus. The weight loss of 3 lb in a week is concerning and requires immediate medical attention to prevent complications. The other choices (B, C,
D) are common discomforts during pregnancy and not considered urgent issues that require immediate reporting to the provider. Mood swings (
B) are a normal part of hormonal changes in pregnancy, nosebleeds (
C) can be due to increased blood volume and nasal congestion, and increased vaginal discharge (
D) is a common physiological change in pregnancy.
Question 4 of 5
A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?
Correct Answer: C
Rationale: The correct answer is C: Biophysical profile (BPP). At 41 weeks gestation with a positive contraction stress test, the BPP is indicated to assess fetal well-being. BPP evaluates fetal heart rate, fetal movements, fetal tone, amniotic fluid volume, and sometimes a nonstress test. This test provides information on fetal oxygenation and overall health. The other choices are incorrect because:
A) Percutaneous umbilical blood sampling is used to assess fetal blood gases and acid-base balance, typically in cases of suspected fetal compromise.
B) Amnioinfusion involves infusing sterile fluid into the amniotic cavity, usually to correct oligohydramnios.
D) Chorionic villus sampling is a prenatal diagnostic test used to detect genetic abnormalities.
Question 5 of 5
A nurse is preparing to administer an IM injection to a newborn. Which of the following sites should the nurse select?
Correct Answer: A
Rationale: The correct site for an IM injection in a newborn is the vastus lateralis muscle. This site is recommended for infants due to the larger muscle mass, reduced risk of injury to nerves and blood vessels, and better absorption of the medication. The vastus lateralis is located on the lateral aspect of the thigh and is easily accessible for injections. In contrast, the dorsogluteal site is not recommended in infants due to the proximity of the sciatic nerve and the risk of injury. The deltoid muscle is typically used for older children and adults, not newborns. The rectus femoris muscle is not a commonly used site for IM injections in newborns. Selecting the vastus lateralis ensures safe and effective administration of the medication.