ATI RN Maternal Newborn level 3 Final Exam 2023 (All Correct Answers). Maternal-Child Nursing -Nurselytic

Correct Answer: B

Rationale: The correct answer is B: Ensure that the fetal head is engaged. This is crucial before performing an amniotomy to prevent umbilical cord prolapse. If the fetal head is not engaged, there is a risk of cord compression. Placing the client in the left lateral position (choice
A) is not directly related to the amniotomy procedure. Giving the provider clean gloves (choice
C) is important for infection control but not specifically related to ensuring fetal head engagement. Checking the client's temperature (choice
D) is important for monitoring but not a priority before an amniotomy.

Correct Answer: D

Rationale: The correct answer is D. The nurse should auscultate the fetal heart rate for a client who has felt quickening for the first time during the prenatal visit. Quickening is the first fetal movements felt by the mother, typically occurring around 18-20 weeks gestation. Auscultating the fetal heart rate confirms the presence of fetal life and ensures the fetus is developing appropriately. This step is crucial in assessing fetal well-being and monitoring for any potential complications.


Choice A: A client with a molar pregnancy does not have a viable fetus; auscultating the fetal heart rate is not necessary.

Choice B: A client with a crown-rump length of 7 weeks gestation may be too early for fetal heart rate detection using auscultation.

Choice C: A positive urine pregnancy test alone does not indicate fetal viability; auscultation is needed to assess the fetus.
In summary, choice D is correct as it aligns with the timing of fetal movement and the need to assess

Correct Answer: D

Rationale: The correct answer is D: Sternal retractions. Sternal retractions in a newborn indicate respiratory distress, potentially due to a blocked airway or difficulty breathing. The nurse should intervene immediately to ensure the newborn's airway is clear and that they are able to breathe properly.
A: Molding is the overlapping of cranial bones during birth, a common and temporary finding.
B: Vernix Caseosa is a protective coating on the newborn's skin and is normal.
C: Acrocyanosis is the bluish discoloration of the hands and feet, a common finding in newborns due to immature circulation.

Correct Answer: B

Rationale: The correct answer is B: Avoid using lotion or ointment on the newborn skin. This is because lotions or ointments can interfere with the effectiveness of phototherapy by blocking the light from reaching the skin. Dressing the newborn in lightweight clothing (
Choice
A) is important to maximize skin exposure to the light. Keeping the newborn supine throughout treatment (
Choice
C) is not directly related to the effectiveness of phototherapy. Measuring the newborn's temperature every 8 hours (
Choice
D) is important but not specifically related to phototherapy.

Correct Answer: C

Rationale: The correct answer is C. The nurse should assess the client with hyperemesis gravidarum and a sodium level of 110 mEq/L first. This client is at risk for severe dehydration and electrolyte imbalance, which can lead to serious complications such as metabolic acidosis or organ dysfunction. Prompt assessment and intervention are crucial to stabilize the client's condition.

Choice A is not the priority as a client with diabetes mellitus and an HbA1c of 5.8% is within the target range indicating good glycemic control.
Choice B, a client with preeclampsia and a creatinine level of 1.1 mg/dL, requires monitoring but is not as urgent as the client with hyperemesis gravidarum.
Choice D, a client with placenta previa and a hematocrit of 36%, also needs monitoring but is not as urgently concerning as electrolyte imbalance.