ATI RN
ATI RN Maternal Newborn level 3 Final Exam 2023 (All Correct Answers). Maternal-Child Nursing Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has received an epidural during labor. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Position a wedge under the client's left hip. Placing a wedge under the left hip helps to optimize the distribution of the epidural medication, ensuring even pain relief. This positioning can also help prevent uneven spread of the medication, reducing the risk of complications such as uneven numbness or motor weakness.
Choice B: Placing the client in the lithotomy position is incorrect because this position is not recommended for clients with epidurals as it may increase the risk of hypotension.
Choice C: Assisting the client to a knee-chest position is incorrect because this position is not suitable for clients with epidurals and may cause discomfort or compromise the effectiveness of the epidural.
Choice D: Elevating the head of the client's bed to 90% is incorrect as it is not directly related to optimizing the effects of the epidural.
In summary, positioning a wedge under the client's left hip is the most appropriate action to ensure optimal distribution and effectiveness
Question 2 of 5
A nurse on a labor and delivery unit is receiving infection control standards with a newly licensed nurse. The nurse should instruct the newly licensed nurse to don gloves for which of the following procedures?
Correct Answer: D
Rationale: The correct answer is D: Performing umbilical cord care. Gloves should be worn when performing this procedure to prevent potential infection transmission. The umbilical cord stump is a point of entry for pathogens, making it important to maintain strict infection control. Assisting a mother with breastfeeding (
A) does not require gloves unless there are open wounds or sores on the mother's breast. Performing a newborn’s initial bath (
B) does not necessitate gloves unless there are specific concerns like skin conditions. Administering the measles, mumps, rubella vaccine (
C) typically requires clean, not sterile, technique. In summary, wearing gloves during umbilical cord care is essential to prevent infection transmission, making it the correct choice in this scenario.
Question 3 of 5
A nurse is caring for four newborns. Which of the following newborns should the nurse assess first?
Correct Answer: A
Rationale: The correct answer is A: newborn who has nasal flaring. Nasal flaring indicates respiratory distress, which is a priority concern in newborns as it can lead to hypoxia. The nurse should assess this newborn first to ensure adequate oxygenation.
B: Subconjunctival hemorrhage is common and not an urgent issue.
C: Overlapping suture lines are normal in newborns and do not require immediate attention.
D: Not passing rust-stained urine could indicate a metabolic issue but is not as urgent as respiratory distress.
Question 4 of 5
A nurse is assisting with an amniotomy on a client who is in labor. Which of the following situations should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Ensure that the fetal head is engaged. This is crucial before performing an amniotomy to prevent umbilical cord prolapse. If the fetal head is not engaged, there is a risk of cord compression. Placing the client in the left lateral position (choice
A) is not directly related to the amniotomy procedure. Giving the provider clean gloves (choice
C) is important for infection control but not specifically related to ensuring fetal head engagement. Checking the client's temperature (choice
D) is important for monitoring but not a priority before an amniotomy.
Question 5 of 5
A nurse is planning care for a client who is scheduled for a cesarian birth. Which of the following interventions should the nurse include in the plan of care?
Correct Answer: B
Rationale: The correct answer is B: Perform a surgical time out. This step is crucial before any surgical procedure, including a cesarean birth, to ensure patient safety. During the time out, the surgical team verifies the patient's identity, correct procedure, correct site, and other essential details to prevent errors. In contrast, choice A is outdated practice as current guidelines allow clear fluids up to a few hours before surgery.
Choice C is unnecessary and can increase the risk of infection.
Choice D is incorrect as metal hairpins are not recommended due to the risk of injury and interference with surgical equipment.