ATI RN
RN ATI Maternal Newborn 2023 with NGN Questions
Extract:
Question 1 of 5
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
Correct Answer: A
Rationale: The correct answer is A. Substernal retractions in a 16-hour-old newborn indicate respiratory distress and may be a sign of an underlying issue such as respiratory distress syndrome. This finding requires immediate attention from the healthcare provider to assess and manage the newborn's respiratory status.
Choices B, C, and D are not as concerning in a newborn of this age. Acrocyanosis is a common finding in newborns due to immature circulation. Overlapping suture lines can be normal due to the molding process during birth. A head circumference of 33 cm falls within the normal range for a newborn.
Therefore, these findings do not require immediate reporting to the provider.
Question 2 of 5
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?
Correct Answer: D
Rationale: The correct answer is D: Instruct the client to press the provided button each time fetal movement is detected. This action is crucial during a nonstress test as it helps monitor fetal heart rate in response to movement, indicating a healthy fetal status. Pressing the button when fetal movement is felt ensures accurate data collection. Maintaining NPO status (
A) is not required for a nonstress test. Placing the client in a supine position (
B) can reduce blood flow to the fetus and is contraindicated. Instructing the client to massage the abdomen (
C) may interfere with the natural fetal movement patterns and affect test results.
Question 3 of 5
A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution. This is crucial to assess for any potential hypotension, a common side effect of epidural anesthesia. Close monitoring allows for prompt intervention if hypotension occurs, ensuring the client's safety.
Choice A is incorrect because placing the client in a supine position following epidural anesthesia can lead to hypotension.
Choice B is incorrect as administering dextrose solution is not necessary for epidural anesthesia.
Choice D is incorrect as NPO status is not required for epidural anesthesia administration.
Question 4 of 5
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on bed rest. This is important to prevent dislodgement of the clot and further complications associated with thrombophlebitis. Moving the client around can increase the risk of clot migration. Administering aspirin for pain (choice
A) is not appropriate as it can increase the risk of bleeding with heparin therapy. Massaging the affected leg every 12 hours (choice
C) can also dislodge the clot and is contraindicated. Applying cold compresses to the affected calf (choice
D) can also increase the risk of clot dislodgement.
Therefore, the best action is to maintain the client on bed rest to minimize the risk of complications.
Question 5 of 5
A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: C
Rationale: The correct answer is C because continuing to take insulin even during nausea and vomiting is crucial to prevent complications of hyperglycemia. Nausea and vomiting can lead to decreased food intake, risking hypoglycemia without insulin.
Choice A is incorrect as insulin needs may decrease in the first trimester.
Choice B is incorrect as moderate exercise is not recommended if blood glucose is 250 or greater.
Choice D is incorrect as a bedtime snack high in refined sugar can lead to unstable blood sugar levels.