ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 of 5
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Minimal arm recoil. In a premature newborn born at 26 weeks of gestation, minimal arm recoil is expected according to the New Ballard Score. This is because premature infants have immature muscle tone, which leads to reduced arm recoil. This finding is consistent with the developmental stage of a preterm infant.
Other choices are incorrect:
B: Popliteal angle of 90° - This would not be expected in a newborn born at 26 weeks of gestation as their joints would be more flexible.
C: Creases over the entire foot sole - Premature infants may have fewer creases on their soles due to immaturity.
D: Raised areolas with 3 to 4 mm buds - Breast development is not expected in a newborn born at 26 weeks of gestation.
Question 2 of 5
A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: D
Rationale:
Correct Answer: D. "I will eliminate products that contain dairy from my diet."
Rationale: Hyperemesis gravidarum is severe nausea and vomiting during pregnancy, and dairy products can be difficult to digest and may worsen symptoms. Eliminating dairy can help reduce nausea and improve tolerance of food. This statement demonstrates an understanding of dietary modifications to manage hyperemesis gravidarum.
Summary of Other
Choices:
A: Incorrect. Eating foods based on taste without considering nutritional balance may not provide adequate nutrients needed during pregnancy.
B: Incorrect. Avoiding a bedtime snack may not necessarily address the underlying cause of hyperemesis gravidarum and may lead to hunger and poor nutrition.
C: Incorrect. Hot tea may not necessarily alleviate symptoms of hyperemesis gravidarum and might not address the dietary needs of the client.
E: Not provided.
F: Not provided.
G: Not provided.
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. A uterus palpated to the right above the umbilicus in a postpartum client indicates a full bladder displacing the uterus. This can lead to uterine atony and increase the risk of postpartum hemorrhage. By assisting the client to empty their bladder, the nurse can help the uterus contract properly and prevent complications.
Other choices are incorrect:
A: Reassessing in 2 hours does not address the immediate issue of a full bladder causing uterine displacement.
B: Administering simethicone is used for gas relief and is not relevant in this situation.
D: Instructing the client to lie on their right side does not address the underlying issue of a full bladder.
In summary, emptying the bladder is crucial to prevent complications post-vaginal delivery, making it the most appropriate intervention in this scenario.
Question 4 of 5
A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Facial petechiae. A nuchal cord occurs when the umbilical cord is wrapped around the baby's neck. This can cause pressure on the blood vessels, leading to tiny red or purple spots called petechiae on the baby's face. This is due to the rupture of small blood vessels under the skin. Telangiectatic nevi (choice
A) are unrelated birthmarks. Periauricular papillomas (choice
C) are benign skin-colored growths near the ears. Erythema toxicum (choice
D) is a common rash in newborns not associated with a nuchal cord.
Question 5 of 5
A nurse is caring for a client who is hypotensive following the administration of epidural anesthesia. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Turn the client to a side-lying position. This action helps improve venous return to the heart and increases blood pressure in hypotensive clients. It prevents aortocaval compression, which can lead to decreased cardiac output. Turning the client to a side-lying position is a simple and effective intervention to manage hypotension in this situation.
Other choices are incorrect:
B: Applying oxygen is not the priority in this scenario as the client's hypotension is likely due to the epidural anesthesia and not respiratory distress.
C: Massaging the fundus is not indicated as the client is not postpartum or experiencing uterine atony.
D: Assisting the client to empty their bladder may be important but does not directly address the hypotension caused by epidural anesthesia.