ATI RN
ATI RN Maternal Newborn level 3 Final Exam 2023 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is 36 weeks gestation and has MRSA. Which of the following isolation precautions should the nurse initiate?
Correct Answer: B
Rationale: The correct answer is B: Contact precautions. MRSA is primarily spread through direct contact with an infected person or contaminated surfaces. By implementing contact precautions, the nurse can prevent the transmission of MRSA to other patients or healthcare workers. Droplet precautions (choice
A) are used for diseases spread via respiratory droplets, such as influenza. Airborne precautions (choice
C) are for diseases transmitted through small particles in the air, like tuberculosis. Protective environment (choice
D) is used for immunocompromised patients to protect them from environmental pathogens. In this scenario, contact precautions are the most appropriate choice to prevent the spread of MRSA.
Question 2 of 5
A nurse is assessing a client who is 27 weeks of gestation and has pre eclampsia. Which of the following findings should the nurse report to the provider?
Correct Answer: B
Rationale: The correct answer is B: Platelet count 60,000/ mm. In pre-eclampsia, a low platelet count indicates thrombocytopenia, a serious complication that can lead to bleeding. This finding should be reported promptly to the provider for further evaluation and management. A: Hemoglobin level is within normal range and not a priority in pre-eclampsia. C: Creatinine level is normal and not directly related to the complications of pre-eclampsia. D: Urine protein concentration is elevated, which is expected in pre-eclampsia and should be monitored, but not as urgent as low platelet count.
Question 3 of 5
A nurse is caring for a client who has placenta previa. Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Painless, vaginal bleeding. Placenta previa is a condition where the placenta partially or completely covers the cervix, leading to painless, bright red bleeding in the third trimester. This occurs because the placenta is located close to or over the cervical opening, causing it to bleed with minimal trauma. It is important for the nurse to recognize this sign as it can lead to maternal and fetal complications if not managed promptly.
Choices A, C, and D are incorrect because they do not align with the typical presentation of placenta previa. A firm rigid abdomen is more indicative of a condition like placental abruption. Uterine hypertonicity is not a common finding in placenta previa. Persistent headache is not a characteristic symptom of placenta previa and may be indicative of other conditions like preeclampsia.
Question 4 of 5
A nurse is caring for a client who reports spontaneous rupture. The nurse observed fetal bradycardia in the FHR tracing and notices the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following should the nurse take next?
Correct Answer: D
Rationale: The correct answer is D: Cover the umbilical cord with sterile saline saturated towel. This is the correct next step because it helps prevent compression of the cord, which could lead to fetal compromise. By covering the cord with a sterile saline towel, the nurse can protect it from drying out and maintain a moist environment. This step is crucial in preventing further harm to the fetus.
A: Initiate an infusion of IV fluids for the client - This is not the priority at this moment. The focus should be on managing the umbilical cord prolapse and fetal distress.
B: Perform vaginal examination by applying upward pressure on the presenting part - This action could potentially worsen the situation by further compressing the cord. It is not recommended in this scenario.
C: Administer oxygen via non-rebreather mask at 8L/min - While oxygenation is important for the client and fetus, managing the umbilical cord prolapse takes precedence in this situation.
In summary, covering
Question 5 of 5
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lap. Which of the following actions should the nurse include?
Correct Answer: C
Rationale: The correct answer is C: Ensure the newborn's eyes are closed beneath the shield. This is crucial during phototherapy to protect the newborn's eyes from potential damage caused by the bright lights. Newborns undergoing phototherapy should have their eyes shielded with protective eye coverings to prevent eye damage.
Choice A is incorrect as lotion can intensify the effects of phototherapy.
Choice B is incorrect as the newborn should be undressed to maximize skin exposure.
Choice D is incorrect as glucose water is not indicated for phototherapy and may interfere with treatment.