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 4
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 32-year-old female 3 days postpartum via cesarean, reports chills, warm skin, 3+ edema, large lochia rubra, pain 5/10, temp 38.3°C, HR 110/min, BP 140/90.
Question 2 of 4
Which of the following findings require immediate follow-up? (Select all that apply)
Correct Answer: A, B, D, E, G
Rationale: Temp 38.3°C, HR 110/min, BP 140/90, large lochia rubra, and 3+ edema indicate infection, hemorrhage, or DVT, requiring urgent follow-up.
Extract:
A 32-year-old female in postpartum unit, cesarean birth due to preeclampsia, given misoprostol, pale, dizzy, cool/clammy skin, no urine since medication.
Question 3 of 4
The nurse is assessing the client 1 hour later. How should the nurse interpret the findings?
| Findings | condition improving | condition worsening | unrelated to the diagnosis |
|---|---|---|---|
| Fundus 2 cm above umbilicus | |||
| BP 90/60, | |||
| HR 110/min | |||
| Heavy bleeding | |||
| Dizziness | |||
| Cloudy urine |
Correct Answer:
Rationale: Fundus 2 cm above, HR 110/min, heavy bleeding, dizziness worsening (hemorrhage); BP 90/60 improving (post-preeclampsia); cloudy urine unrelated.
Extract:
A newborn, 4 hours old, born at 41 weeks, mother with syphilis and cannabis use, jittery, weak cry, mottled extremities, rapid respirations.
Question 4 of 4
Complete the diagram:
Action to Take
Potential Condition
Parameter to Monitor
Correct Answer: A
Rationale: Neonatal hypoglycemia fits jitteriness and glucose 30 mg/dL; dextrose IV and monitoring glucose correct it; glucose and HR monitor progress.
Extract:
A 36-hour-old male newborn, born at 39 weeks, breastfeeding 3-4 times/day, voided once, no meconium, yellow sclera.
Question 5 of 4
Which of the following findings should the nurse report to the provider? (Select all that apply)
Correct Answer: A, C, D
Rationale: Positive Coombs test, yellow sclera, and no meconium suggest hemolysis, jaundice, and possible obstruction, requiring provider attention.