ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake 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 may indicate respiratory distress, which requires immediate attention from the provider to prevent further complications. Acrocyanosis (choice
B) is a common finding in newborns and is considered normal. Overlapping suture lines (choice
C) can be a result of molding during the birth process and typically resolve on their own. A head circumference of 33 cm (13 in) (choice
D) falls within the normal range for a newborn and does 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 glucose supply to the brain, causing neurologic dysfunction. Hypertonia (choice
A) is more indicative of hypocalcemia. Increased feeding (choice
B) is not a typical manifestation of hypoglycemia. Hyperthermia (choice
C) is not directly related to hypoglycemia. In summary, respiratory distress is a key sign of hypoglycemia in a late preterm newborn, while the other choices are not specific indicators.
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. Palpating the uterus above the umbilicus indicates uterine atony, a common cause of postpartum hemorrhage. A full bladder can displace the uterus further, exacerbating the risk of hemorrhage. Emptying the bladder will allow the uterus to contract properly and reduce the risk. Reassessing the client in 2 hours (
A) delays immediate intervention. Administering simethicone (
B) is for gas relief and not relevant in this situation. Instructing the client to lie on their right side (
D) does not address the underlying issue of uterine atony.
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 important during phototherapy as it maximizes the skin exposure to the light, aiding in the breakdown of bilirubin. Removing clothing allows for better absorption of the therapeutic light.
A is incorrect as water should not be given to a newborn without a specific medical indication. B is unnecessary and may interfere with the effectiveness of the phototherapy. D is incorrect as a rash is a common side effect of phototherapy and does not necessarily warrant discontinuation of treatment.
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. This action is essential during a nonstress test as it helps to monitor the baby's heart rate in response to its movements, providing crucial information about fetal well-being. Pressing the button allows the nurse to correlate fetal movements with changes in the heart rate, helping to assess the baby's overall health and response to stimuli. Maintaining the client NPO (
A) is not necessary for a nonstress test. Placing the client in a supine position (
B) can decrease blood flow to the baby and is not recommended. Instructing the client to massage the abdomen (
C) may artificially stimulate fetal movements, affecting the accuracy of the test results.