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 is 1 day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Assess the newborn's latch while breastfeeding. The nurse should assess the newborn's latch to ensure proper attachment to the breast, which can alleviate sore nipples. This step is crucial in addressing the root cause of the issue. Waiting 4 hours between feedings (
A) can lead to engorgement and affect milk supply. Limiting breastfeeding time to 5 minutes (
C) may not be sufficient for adequate feeding. Offering supplemental formula (
D) can interfere with establishing breastfeeding and may not address the underlying latch issue.
Question 2 of 5
A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Decreased platelet count. In ITP, the immune system attacks and destroys platelets, leading to a low platelet count (thrombocytopenia). This can result in increased bleeding tendencies.
B: Increased ESR is not typically associated with ITP.
C: Decreased megakaryocytes is not expected in ITP as these are the precursors of platelets.
D: Increased WBC is not a characteristic finding in ITP.
Therefore, the nurse should expect a decreased platelet count in a client with postpartum ITP.
Question 3 of 5
A nurse is caring for a client who is in labor and reports increasing rectal pressure. They are experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that their cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?
Correct Answer: B
Rationale: The correct answer is B: Active phase of labor. At 9 cm dilation, the client is transitioning from the latent phase to the active phase. In the active phase, the cervix typically dilates from 6 to 10 cm. The client's contractions are close together and long-lasting, indicating active labor. Rectal pressure is common during the active phase as the baby descends further. The passive descent (
A) phase occurs later in labor when the cervix is fully dilated, and the client is ready to push. Early phase (
C) is characterized by slow cervical dilation from 0 to 6 cm. Descent (
D) phase is not a recognized phase of labor.
Question 4 of 5
A nurse is admitting a client to the birthing unit who reports her contractions started 1 hr ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions?
Correct Answer: D
Rationale: The correct answer is D: Postpartum hemorrhage. The client being 80% effaced and 8 cm dilated indicates she is in active labor, not pregnant with an ectopic pregnancy. Hyperemesis gravidarum is severe nausea and vomiting during pregnancy, which is not related to the client's current condition. Incompetent cervix would present earlier in pregnancy with painless cervical dilation, not during active labor. Postpartum hemorrhage is a risk due to the advanced dilation and effacement, making the uterus more prone to atony and excessive bleeding after delivery.
Question 5 of 5
A nurse is teaching about home safety with a client who is 2 days postpartum. Which of the following instructions should the nurse include in the teaching?
Correct Answer: D
Rationale: The correct answer is D: Wash your baby's face with plain water. This instruction is important for newborn care as it helps prevent skin irritation and infection. Washing with plain water is gentle and safe for the baby's delicate skin. Other choices are incorrect: A is incorrect because bathing immediately after a feeding can lead to discomfort and potential regurgitation. B is incorrect as bumper pads pose a suffocation hazard for infants. C is incorrect as a soft mattress increases the risk of sudden infant death syndrome.