ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 of 5
A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?
Correct Answer: B
Rationale:
Correct Answer: B - Provide the client with photos of the fetus.
Rationale: Providing photos of the stillborn fetus allows the client to have tangible memories and facilitates the grieving process. It helps validate the loss and provides closure. Seeing and holding the photos can aid in acknowledging the reality of the situation and promote healing.
Summary of Incorrect
Choices:
A: Limiting the time the fetus is in the room may not be necessary and could hinder the client's grieving process.
C: Instructing the client about an autopsy within 24 hours might add unnecessary stress and pressure during an already challenging time.
D: Informing the client about a law requiring them to name the fetus is inaccurate and could add undue stress and confusion to the client.
Question 2 of 5
A nurse is caring for a client who is 1 day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Assess the newborn's latch while breastfeeding. The nurse should assess the newborn's latch to ensure proper attachment to the breast, which can alleviate sore nipples. This step is crucial in addressing the root cause of the issue. Waiting 4 hours between feedings (
A) can lead to engorgement and affect milk supply. Limiting breastfeeding time to 5 minutes (
C) may not be sufficient for adequate feeding. Offering supplemental formula (
D) can interfere with establishing breastfeeding and may not address the underlying latch issue.
Question 3 of 5
A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Decreased platelet count. In ITP, the immune system attacks and destroys platelets, leading to a low platelet count (thrombocytopenia). This can result in increased bleeding tendencies.
B: Increased ESR is not typically associated with ITP.
C: Decreased megakaryocytes is not expected in ITP as these are the precursors of platelets.
D: Increased WBC is not a characteristic finding in ITP.
Therefore, the nurse should expect a decreased platelet count in a client with postpartum ITP.
Question 4 of 5
A nurse is admitting a client to the labor and delivery unit when the client states, 'My water just broke.' Which of the following interventions is the nurse's priority?
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. This is the priority intervention because assessing the fetal heart rate (FHR) is crucial to ensuring the well-being of the fetus after the client's water has broken. Monitoring the FHR can help detect any signs of distress or complications that may arise. Performing Nitrazine testing (
A) and assessing the fluid (
B) can provide additional information, but monitoring the FHR takes precedence due to its direct impact on fetal well-being. Checking cervical dilation (
C) is important but not as urgent as monitoring the FHR in this situation.
Question 5 of 5
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)
Correct Answer: A,C
Rationale:
Correct Answer: A, C
Rationale:
A: Flaccid uterus indicates uterine atony, a common postpartum complication causing excessive bleeding. Oxytocin helps contract the uterus, reducing bleeding.
C: Excess vaginal bleeding is a sign of postpartum hemorrhage. Oxytocin helps by stimulating uterine contractions to control bleeding.
B: Cervical laceration doesn't directly relate to oxytocin administration. It requires repair and not oxytocin.
D: Increased afterbirth cramping is a normal response after delivery, not a direct indication for oxytocin.