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 has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?
Correct Answer: D
Rationale: The correct answer is D: Urine negative for ketones. In hyperemesis gravidarum, ketones in urine indicate dehydration and increased risk of metabolic acidosis. Reporting this finding is crucial for adjusting the client's fluid replacement therapy. Blood pressure and heart rate within normal range (A,
B) are expected during IV fluid replacement. Adequate urine output (
C) indicates proper kidney perfusion. However, urine negative for ketones (
D) is concerning as it suggests inadequate fluid intake or continued vomiting.
Question 2 of 5
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
Correct Answer: C
Rationale:
Correct Answer: C - Remove all clothing from the newborn except the diaper.
Rationale: Phototherapy involves exposing the newborn's skin to light to breakdown excess bilirubin.
To maximize the effectiveness of phototherapy, the newborn should have as much skin exposed to the light as possible. Removing all clothing except the diaper ensures that the most surface area is exposed to the light, improving bilirubin breakdown.
Summary of other choices:
A: Feeding water is not directly related to phototherapy for hyperbilirubinemia.
B: Applying lotion does not aid in the effectiveness of phototherapy.
D: Discontinuing therapy due to a rash may compromise the treatment of hyperbilirubinemia.
Question 3 of 5
A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: D
Rationale: The correct answer is D: "I will eliminate products that contain dairy from my diet." This is the correct choice because dairy products can exacerbate symptoms of hyperemesis gravidarum due to their high fat content, which can be difficult to digest during pregnancy. By eliminating dairy products, the client can potentially reduce nausea and vomiting.
A: "I will eat foods that taste good instead of balancing my meals." This choice is incorrect because focusing solely on taste without considering nutritional balance may not address the client's specific dietary needs during hyperemesis gravidarum.
B: "I will avoid having a snack before I go to bed each night." This choice is not directly related to managing hyperemesis gravidarum through dietary changes.
C: "I will have a cup of hot tea with each meal." While hot tea can be soothing, it may not address the specific dietary modifications needed for managing hyperemesis gravidarum.
Question 4 of 5
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?
Correct Answer: B
Rationale: The correct answer is B: Chin quivering. Chin quivering is a common sign of pain in newborns. It indicates discomfort and distress. Decreased heart rate (
A), pinpoint pupils (
C), and slowed respirations (
D) are not reliable indicators of pain in newborns. Heart rate may decrease as a response to pain, but it can also be affected by other factors. Pinpoint pupils are more indicative of drug use or neurological issues. Slowed respirations may be a sign of relaxation, not necessarily pain. Chin quivering, on the other hand, is a direct physical manifestation of pain and should be recognized by the nurse as a sign to address the newborn's discomfort.
Question 5 of 5
A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow.
Correct Answer: A,B,CD
Rationale: The correct sequence for performing Leopold maneuvers is A, B, C, and D. Firstly, palpating the fundus (
A) helps identify the fetal part and presentation. Secondly, determining the location of the fetal back (
B) provides information on the fetal lie. Next, palpating for the fetal part at the inlet (
C) helps confirm the presenting part. Lastly, identifying the attitude of the head (
D) provides important information on the fetal position for delivery. This sequence ensures a systematic approach to assessing the fetal presentation and position.
Choices E, F, and G are incorrect as they do not follow the logical order of Leopold maneuvers and may lead to inaccurate assessment.