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 cause hypotension, respiratory depression, and cardiac arrest if given in excess. Calcium gluconate is the antidote for magnesium sulfate toxicity, as it helps reverse the effects of magnesium sulfate on the neuromuscular and cardiac systems. Having calcium gluconate readily available ensures prompt treatment in case of magnesium sulfate toxicity.
Incorrect choices:
A: Restrict hourly fluid intake to 150 mL/hr - Fluid restriction is not necessary for magnesium sulfate administration in preeclampsia.
C: Assess deep tendon reflexes every 6 hr - Although assessing reflexes is important when administering magnesium sulfate, the frequency should be more frequent than every 6 hours.
D: Monitor intake and output every 4 hr - While monitoring intake and output is important, it is not the most crucial action to take when administering magnesium sulfate in preeclampsia.
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 12 hours after birth can indicate hyperbilirubinemia, which may require medical intervention to prevent complications such as kernicterus. Acrocyanosis (
A) is a common finding in newborns due to immature circulation. Transient strabismus (
B) is a temporary misalignment of the eyes. Caput succedaneum (
D) is localized swelling on a newborn's head from pressure during birth and resolves on its own.
Question 3 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). At 41 weeks gestation with a positive contraction stress test, the BPP is indicated to assess fetal well-being. BPP evaluates fetal heart rate, fetal movements, fetal tone, amniotic fluid volume, and sometimes a nonstress test. This test provides information on fetal oxygenation and overall health. The other choices are incorrect because:
A) Percutaneous umbilical blood sampling is used to assess fetal blood gases and acid-base balance, typically in cases of suspected fetal compromise.
B) Amnioinfusion involves infusing sterile fluid into the amniotic cavity, usually to correct oligohydramnios.
D) Chorionic villus sampling is a prenatal diagnostic test used to detect genetic abnormalities.
Extract:
A nurse is caring for a client who is pregnant in an antepartum clinic.
Vital Signs
0900:
Temperature 36.6°C (97.9°F)
Heart rate 88/min
Respiratory rate 18/min
Blood pressure 130/70 mm Hg
Oxygen saturation 97% on room air
1000:
Heart rate 76/min
Respiratory rate 20/min
Blood pressure 138/68 mm Hg
Oxygen saturation 98% on room air
Question 4 of 5
Which of the following findings should the nurse report to the provider?Select the 3 findings that should be reported.
Correct Answer: A,B,D
Rationale: The nurse should report uterine contractions (
A) as they can indicate preterm labor. Fetal heart rate (
B) should be reported to monitor fetal well-being. Vaginal examination (
D) findings are important to assess cervical changes. Gestational age (
C) and maternal blood pressure (E) are routine assessments and do not necessarily require immediate reporting.
Extract:
A nurse is caring for a newborn who is 48 hr old.
Exhibit 1
Vital Signs
Day 2, 0900:
Heart rate 174/min
Respiratory rate 88/min
Temperature 36.1° C (97.0° F)
Oxygen saturation 97% on room air
Exhibit 2
Diagnostic Results
Day 1, 0800: Newborn results
Blood type: A+
Urine toxicology screen: positive marijuana
Day 2, 0800: Newborn results
Total bilirubin 10 mg/dL (1.0 to 12.0 mg/dL)
Day 2, 0915:
Blood glucose: 38 mg/dL (expected value greater than 40 to 45 gm/dL)
Complete the diagram by dragging from the choices below to specify what condition the client is
most likely experiencing, 2 actions the nurse should take to address that condition, and 2
parameters the nurse should monitor to assess the client’s progress.
Question 5 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Correct Answer:
Rationale: Action to Take: A, B; Potential Condition: B; Parameter to Monitor: C, E.
Rationale:
1. The potential condition the client is most likely experiencing is Acute bilirubin encephalopathy .
2. The nurse should take the actions of placing the newborn skin to skin on the birthing parent's chest and encouraging breastfeeding to address this condition.
3. Parameters to monitor include monitoring temperature (to assess for hypothermia related to cold stress) and monitoring the bilirubin level (to assess for bilirubin encephalopathy progression).
Summary:
-
Choice A is incorrect as obtaining a prescription for arterial blood gases and planning phototherapy are not directly related to the potential condition.
-
Choice C is incorrect as monitoring stool output, lung sounds, and blood glucose level are not specific to the potential condition identified.
- It's essential to focus on actions and parameters directly related to the identified potential condition for effective client care.