ATI RN
ATI RN Maternal Newborn Latest Update. 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: The correct answer is B: Provide the client with photos of the fetus. This action allows the client to create memories and acknowledge the loss, aiding in the grieving process. It also validates the existence of the stillborn and helps with closure.
A: Limiting the time the fetus is in the room may not address the emotional needs of the client.
C: Instructing the client about a mandatory autopsy may be insensitive and overwhelming during this emotional time.
D: Informing the client about a law requiring them to name the fetus is incorrect and may add unnecessary stress.
Question 2 of 5
A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply.)
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D.
A) Labor induction with oxytocin can lead to uterine hyperstimulation, increasing the risk of postpartum hemorrhage.
C) Vacuum-assisted delivery can cause trauma to the birth canal, leading to excessive bleeding.
D) A history of uterine atony indicates a weak uterine muscle tone, which is a significant risk factor for postpartum hemorrhage.
B) Newborn weight and E) history of human papillomavirus are not directly related to postpartum hemorrhage.
Extract:
A nurse is caring for a newborn.
Exhibit 1
Medical History
1600:
Apgar score 9 at 1 min and 9 at 5 min
Birth weight 4,706 g (10 lb 6 oz)
Gestational age 40 weeks
Difficult vaginal birth with shoulder dystocia. Exhibit 2
Nurses' Notes
1700:
Newborn is active and moves all extremities except for right arm. No spontaneous movement of
the right arm noted. Right arm remains at side during Moro reflex. Exhibit 3
Physical Examination
1830:
Absent Moro reflex noted in right arm.
Right shoulder and arm are internally rotated and adducted. Elbow extended. Forearm pronated
with wrist and fingers flexed. Diagnosis: Brachial plexus injury resulting in Erb-Duchenne (Erb's
palsy) paralysis.
Question 3 of 5
Which of the following actions should the nurse plan to implement? For each potential nursing action, click to specify if the intervention is indicated or contraindicated for the newborn.
Correct Answer:
Rationale:
Correct Answer: B: Assess for grasp reflex in the affected extremity.
Rationale: The correct action is to assess for the grasp reflex in the affected extremity. This is indicated to evaluate the newborn's neurological function and muscle strength. The grasp reflex is a normal developmental milestone that should be present in newborns. It helps assess the integrity of the nervous system and motor function in the affected arm.
Summary of Incorrect
Choices:
A: Educating parents to begin range of motion exercises after 1 week is contraindicated as it may cause further harm or injury to the affected arm without proper evaluation.
C: Immobilizing the arm across the abdomen is contraindicated as it may restrict blood flow and hinder proper movement and development of the arm.
D: Instructing parents to limit physical handling for 2 weeks is contraindicated as it may lead to muscle atrophy and delayed recovery.
Extract:
Question 4 of 5
A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Excessive crying. Neonatal abstinence syndrome is characterized by withdrawal symptoms in newborns exposed to drugs in utero. Excessive crying is a common manifestation due to irritability and discomfort. Diminished deep tendon reflexes (choice
A) are not typically associated. Decreased muscle tone (choice
C) is more commonly seen in conditions like hypotonia. Absent Moro reflex (choice
D) is not typically part of neonatal abstinence syndrome.
Question 5 of 5
A nurse is preparing to perform Leopold maneuvers on a client who is at 36 weeks of gestation. Identify the sequence of actions the nurse should take.
Correct Answer: A, B, C, D
Rationale: Action to Take: A, B; Potential Condition: C; Parameter to Monitor: D, E.
The correct sequence for Leopold maneuvers involves instructing the client to empty their bladder to improve visualization and reduce discomfort during the procedure (
A).
Then, positioning the client supine with knees flexed and placing a small, rolled towel under one hip helps provide better access for palpation (
B). Palpating the fetal part positioned in the fundus (
C) is important to determine the baby's position. Following this, palpating the fetal parts along both sides of the uterus (
D) helps assess the baby's presentation and engagement. Monitoring the parameters of fetal parts and fundal height (E) throughout the process ensures accurate assessment of fetal position and presentation.