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 preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Have calcium gluconate readily available. Magnesium sulfate can lead to magnesium toxicity, causing muscle weakness, respiratory depression, and cardiac arrest. Calcium gluconate is the antidote for magnesium sulfate toxicity, as it antagonizes the effects of magnesium on skeletal muscle and cardiac function. It is essential to have calcium gluconate readily available in case of magnesium toxicity.
Incorrect
Choices:
A: Restricting hourly fluid intake is not necessary for a client with preeclampsia receiving magnesium sulfate IV.
C: Assessing deep tendon reflexes every 6 hours is not the most critical action to take to prevent or manage magnesium toxicity.
D: Monitoring intake and output every 4 hours is important for overall client assessment but is not directly related to managing magnesium toxicity in this scenario.
Question 2 of 5
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
Correct Answer: C
Rationale: The correct answer is C: Jaundice. Jaundice in a newborn within the first 24 hours of life can be indicative of pathological conditions such as hemolytic disease or liver dysfunction. The nurse should report this to the provider promptly for further evaluation and management. Acrocyanosis (
A) and caput succedaneum (
D) are common and normal findings in newborns. Transient strabismus (
B) is also common and typically resolves on its own. Make sure to assess for any other concerning symptoms and report them as well.
Question 3 of 5
A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication?
Correct Answer: A
Rationale: The correct answer is A: Depression. Combined oral contraceptives can cause mood changes, including depression, as an adverse effect due to hormonal fluctuations. This is important for the nurse to include in teaching to monitor the client's mental health. Polyuria (
B) is excessive urination, not associated with oral contraceptives. Hypotension (
C) is low blood pressure, not a common adverse effect of oral contraceptives. Urticaria (
D) is hives, typically not linked to this medication.
Question 4 of 5
A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?
Correct Answer: C
Rationale: The correct answer is C: Biophysical profile (BPP). This test evaluates the fetus's well-being by assessing fetal heart rate, fetal breathing movements, fetal movement, fetal tone, and the volume of amniotic fluid. In a client at 41 weeks with a positive contraction stress test, a BPP helps determine if immediate delivery is necessary due to potential fetal distress.
Percutaneous umbilical blood sampling (
A) is used to directly sample fetal blood and assess fetal oxygenation but is not typically indicated in this scenario. Amnioinfusion (
B) is used to relieve variable decelerations during labor by infusing sterile fluid into the amniotic cavity, which is not relevant to a client at 41 weeks of gestation with a positive contraction stress test. Chorionic villus sampling (
D) is an invasive procedure to diagnose genetic abnormalities early in pregnancy and is not indicated for assessing fetal well-being at 41 weeks.
Question 5 of 5
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take?
Correct Answer: B
Rationale:
Rationale:
Choice B is correct because bed rest helps prevent further clot formation and reduces the risk of embolism. Movement can dislodge the clot. Aspirin (
Choice
A) can increase bleeding risk. Massaging (
Choice
C) can dislodge clots. Cold compresses (
Choice
D) can also increase bleeding risk and dislodge clots.