ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 of 5
A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Administer 500 mL lactated Ringer’s IV bolus. This is the correct action because the persistent vaginal bleeding after cesarean birth could indicate hypovolemia, which requires immediate fluid resuscitation to restore blood volume. Fundal massage alone may not be sufficient if the bleeding is ongoing.
Choice A (Replace the surgical dressing) is incorrect because addressing the vaginal bleeding and hypovolemia takes priority over changing the dressing.
Choice B (Evaluate urinary output) is incorrect as it does not address the immediate need to address the potential hypovolemia from the vaginal bleeding.
Choice C (Apply an ice pack to the incision site) is incorrect as it does not address the underlying cause of the persistent vaginal bleeding and hypovolemia.
In summary, administering a fluid bolus is the most appropriate action to address the possible hypovolemia in this situation.
Question 2 of 5
A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Assist the client in pulling their knees toward their abdomen. The McRoberts maneuver involves flexing the client's hips by bringing their knees towards their abdomen. This action helps to widen the pelvic outlet, allowing the baby's shoulder to disengage from the pubic bone and facilitate delivery. Applying pressure to the fundus (choice
A) is not indicated in managing shoulder dystocia. Pressing firmly on the suprapubic area (choice
B) may not effectively resolve the shoulder dystocia. Moving the client onto their hands and knees (choice
C) may not be as effective as the McRoberts maneuver in relieving shoulder dystocia.
Therefore, assisting the client in pulling their knees towards their abdomen is the most appropriate action in this scenario.
Question 3 of 5
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Initiate seizure precautions. Neonatal abstinence syndrome can lead to seizures due to withdrawal from substances. Initiating seizure precautions involves ensuring a safe environment, padding the crib, and monitoring closely for any signs of seizure activity. Monitoring blood glucose every hour (
A) is unnecessary unless there are specific indications. Placing the infant on his back with legs extended (
B) is not directly related to managing neonatal abstinence syndrome. Providing a stimulating environment (
D) can exacerbate symptoms and should be avoided.
Question 4 of 5
A nurse is caring for a client who is at 10 weeks of gestation. Which of the following findings should the nurse report to the provider?
Correct Answer: A
Rationale: The correct answer is A because frequent vomiting with significant weight loss in a short period can indicate hyperemesis gravidarum, a severe form of nausea and vomiting in pregnancy. This condition can lead to dehydration and electrolyte imbalances, posing risks to both the mother and the fetus. The weight loss of 3 lb in a week is concerning and requires immediate medical attention to prevent complications. The other choices (B, C,
D) are common discomforts during pregnancy and not considered urgent issues that require immediate reporting to the provider. Mood swings (
B) are a normal part of hormonal changes in pregnancy, nosebleeds (
C) can be due to increased blood volume and nasal congestion, and increased vaginal discharge (
D) is a common physiological change in pregnancy.
Question 5 of 5
A nurse is caring for a client who is 1 hr postpartum and has uterine atony. The client is exhibiting a large amount of vaginal bleeding. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Anticipate a prescription for misoprostol. Misoprostol is a medication used to help control postpartum hemorrhage by promoting uterine contractions which can help stop the bleeding due to uterine atony. It is important to address the underlying cause of the bleeding to prevent further complications.
Choice A: Administering betamethasone IM is not appropriate in this situation as it is a corticosteroid used to promote fetal lung development in preterm labor, not for controlling postpartum hemorrhage.
Choice B: Avoiding performing sterile vaginal examinations is not helpful in managing postpartum hemorrhage. Vaginal examinations may be necessary to assess the degree of bleeding and uterine tone.
Choice D: Obtaining a specimen for a Kleihauer-Betke test is used to determine the amount of fetal-maternal hemorrhage in cases of Rh incompatibility, not for immediate management of postpart