ATI RN
RN Maternal Nursing OB Newborn 2023 2024 Exam 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. Substernal retractions in a newborn indicate respiratory distress and can be a sign of underlying respiratory issues such as respiratory distress syndrome. The nurse should report this finding to the provider immediately for further evaluation and intervention to ensure the newborn's respiratory status is stable. Acrocyanosis (choice
B) is a common finding in newborns and is not typically concerning. Overlapping suture lines (choice
C) can be a normal variation in newborn skull anatomy. The head circumference of 33 cm (13 in) (choice
D) is within the normal range for a newborn and would not require immediate reporting.
Question 2 of 5
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
Correct Answer: D
Rationale: The correct answer is D: Respiratory distress. Hypoglycemia in a late preterm newborn can lead to respiratory distress due to inadequate energy supply to respiratory muscles. Hypertonia (choice
A) is not a typical manifestation of hypoglycemia. Increased feeding (choice
B) is a compensatory mechanism to raise blood glucose levels. Hyperthermia (choice
C) is not directly related to hypoglycemia.
Therefore, the most appropriate choice indicating hypoglycemia in this scenario is respiratory distress.
Question 3 of 5
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
Correct Answer: C
Rationale: The correct answer is C: Assist the client to empty their bladder. This is the correct intervention because a uterus palpable to the right above the umbilicus indicates a full bladder causing displacement of the uterus. Emptying the bladder will allow the uterus to return to the midline.
Choice A is incorrect as the immediate issue is a full bladder, not requiring a wait of 2 hours.
Choice B (administer simethicone) is incorrect as this medication is for gas relief and not relevant in this scenario.
Choice D (instruct the client to lie on their right side) is incorrect as it does not address the underlying problem of a full bladder.
Question 4 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: The correct answer is C: Remove all clothing from the newborn except the diaper. This is essential during phototherapy to maximize the skin's exposure to the light. The light helps breakdown bilirubin in the skin, reducing jaundice.
Choice A is incorrect as water will not treat hyperbilirubinemia.
Choice B is incorrect as lotions can interfere with the effectiveness of phototherapy.
Choice D is incorrect as a rash is a common side effect of phototherapy and should not lead to discontinuation unless severe.
Question 5 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. During a nonstress test, the client is monitored for fetal heart rate accelerations in response to fetal movement. Instructing the client to press the button each time fetal movement is detected helps correlate fetal heart rate changes with fetal activity. This is crucial in assessing the well-being of the fetus.
A, B, and C are incorrect choices because maintaining the client NPO, placing the client in a supine position, and instructing the client to massage the abdomen are not relevant or necessary for a nonstress test. Option D is the best choice as it directly assists in monitoring fetal well-being during the test.