ATI RN
ATI RN Maternal Newborn 2023 III Questions
Extract:
A nurse is caring for a newborn immediately following birth.
Nurse’s Notes (0700 hrs):
• The newborn is a male, born at 38 weeks gestation via vacuum-assisted vaginal birth. The mother has a history of positive group B streptococcus B-hemolytic and received two doses of ampicillin IV bolus during labor.
• The newborn is placed under a radiant warmer.
• Initial assessment shows the newborn is crying weakly.
• The newborn’s skin color is consistent with genetic background but has acrocyanosis.
• Muscle tone is flaccid.
• Reflex irritability is present with a weak cry.
• The newborn’s temperature is 36.3°C (97.4°F).
Vital Signs (0700 hrs):
• Heart rate: 140/min
• Respiratory rate: 60/min
• Axillary temperature: 36.3°C (97.4°F)
• Oxygen saturation: 92%
Laboratory Findings (0700 hrs):
• WBC count: 15,000/mm³ (9,000 to 30,000/mm³)
• Hgb: 19 g/dL (15 to 24 g/dL)
• Hct: 57% (44 to 70%)
• Blood glucose: 44 mg/dL (40 to 60 mg/dL)
Medications (0700 hrs):
• Erythromycin ophthalmic ointment once 1 to 2 hr after birth
• Hepatitis B vaccine 10 mcg/0.5 mL IM once within 24 hr after birth
• Phytonadione 1 mg IM once 1 to 2 hr after birth
Question 1 of 5
A nurse is assessing the newborn 24 hours later. Based on the exhibits provided, which findings indicate that the newborn’s condition is improving, worsening, or unrelated to the diagnosis?
| Findings | condition improving | condition worsening | unrelated to the diagnosis |
|---|---|---|---|
| WBC count 18,000/mm³ | |||
| Hgb 18 g/dL | |||
| Hct 55% | |||
| Blood glucose 50 mg/dL | |||
| . Axillary temperature 36.8°C | |||
| Heart rate 130/min |
Correct Answer:
Rationale: Regurgitation, mottling, RR 70/min, high-pitched cry worsening (NAS symptoms); strabismus unrelated (normal newborn finding).
Extract:
A nurse is assessing a client who is at 28 weeks of gestation and has a Clostridium difficile infection.
Question 2 of 5
What type of isolation precautions should the nurse initiate for the client?
Correct Answer: C
Rationale: Contact precautions are appropriate for Clostridium difficile, which spreads through direct contact with contaminated surfaces or feces.
Extract:
A nurse is preparing to perform a heel stick on a newborn who has a prescription for a total serum bilirubin.
Question 3 of 5
What actions should the nurse take?
Correct Answer: A
Rationale: Puncturing the lateral side of the heel is correct, minimizing injury risk while obtaining an adequate blood sample.
Extract:
A nurse is calculating the estimated date of birth using Nagele's rule for a client who is pregnant and whose last menstrual cycle started June 21.
Question 4 of 5
What is the estimated date of delivery in the next year?
Correct Answer: C
Rationale: Using Nagele's rule: June 21 - 3 months = March 21, + 7 days = March 28, providing the estimated delivery date.
Extract:
A nurse is assessing the results of a nonstress test for an antepartal client at 35 weeks of gestation.
Question 5 of 5
Which of the following findings should indicate to the nurse the need for further diagnostic testing?
Correct Answer: A
Rationale: Irregular contractions not felt by the client may suggest preterm labor, warranting further testing, unlike reactive NST findings which are normal.