ATI RN
RN ATI Maternal Newborn 2023 with NGN 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. Pain assessment in newborns can be challenging due to their limited ability to communicate. Chin quivering is a common behavioral indicator of pain in newborns. It is a subtle sign of distress and discomfort. Other choices such as decreased heart rate (
A), pinpoint pupils (
C), and slowed respirations (
D) are not reliable indicators of pain in newborns. Decreased heart rate can indicate relaxation, pinpoint pupils are more indicative of opioid use, and slowed respirations might be a sign of sleepiness or relaxation rather than pain.
Question 2 of 5
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: FHR 152/min. At 18 weeks gestation, the fetal heart rate (FHR) should be around 140-160 bpm, making a rate of 152/min within the expected range. This indicates normal fetal cardiac activity and development.
A: Deep tendon reflexes are not typically assessed during routine prenatal visits and are not related to gestational age.
B: Fundal height at 18 weeks should be around the level of the umbilicus, which is closer to 20 cm, not 14 cm.
C: Blood pressure of 142/94 mm Hg is elevated and indicates hypertension, which is not expected at 18 weeks gestation.
E, F, G: No other options provided.
Question 3 of 5
A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct action for the nurse to take first is to determine respiratory function (
Choice
A). This is crucial as an unresponsive client may have compromised breathing which can lead to serious consequences such as hypoxia or respiratory arrest. Assessing respiratory function will help the nurse identify any immediate life-threatening issues and initiate appropriate interventions. Increasing IV fluid rate (
Choice
B) may be important later but is not the priority in this situation. Accessing emergency medications (
Choice
C) and collecting a maternal blood sample (
Choice
D) can also be important but do not address the immediate need to ensure adequate oxygenation. By prioritizing respiratory function assessment, the nurse can quickly address the most critical aspect of the client's care.
Question 4 of 5
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?
Correct Answer: C
Rationale: The correct answer is C: Urine output of 280 mL within 8 hr. In hyperemesis gravidarum, excessive vomiting leads to dehydration and electrolyte imbalance. Monitoring urine output is crucial for assessing renal perfusion. A urine output of 280 mL in 8 hours is low, indicating possible renal impairment. This finding should be reported to the provider for further evaluation and intervention.
Choices A, B, and D are within normal limits for a client with hyperemesis gravidarum and receiving IV fluids. Blood pressure of 105/64 mm Hg is acceptable, heart rate of 98/min is slightly elevated but not alarming, and urine negative for ketones indicates adequate fluid replacement.
Question 5 of 5
A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider?
Correct Answer: B
Rationale: The correct answer is B. Failure to pass meconium stool within the first 24-48 hours after birth can indicate a possible intestinal obstruction or other issues that need immediate attention. Reporting this finding to the provider is crucial for further evaluation and intervention.
Choices A, C, and D are normal findings in newborns and do not require immediate reporting. E, F, and G are not applicable in this context.