ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
Medical History:
• Gravida 2 Para 2
• Cesarean birth
• Deep vein thrombosis with previous pregnancy
• Preeclampsia
• BMI of 32
Question 1 of 5
A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
| Findings 24 hr later | Indication of worsening condition | Indication of improving condition |
|---|---|---|
| Increased warmth in the extremity | ||
| Tachycardia | ||
| Leukocytosis | ||
| Scant lochia rubra | ||
| Decreased extremity edema |
Correct Answer:
Rationale:
Correct Answer:
Rationale:
- Increased warmth in the extremity: Indicates possible worsening of the deep vein thrombosis due to increased blood flow.
- Tachycardia: Indicates worsening circulation and possible pulmonary embolism.
- Leukocytosis: Suggests an inflammatory response to the thrombus, indicating a worsening condition.
- Scant lochia rubra: Not directly related to deep vein thrombosis.
- Decreased extremity edema: Not a relevant indicator for worsening of deep vein thrombosis.
Extract:
Question 2 of 5
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
Correct Answer: C
Rationale: The correct answer is C: Remove all clothing from the newborn except the diaper. This action is essential during phototherapy as it maximizes the area of skin exposed to the light, promoting the breakdown of bilirubin. Adequate hydration is crucial, so option A is incorrect. Applying lotion can interfere with the effectiveness of the therapy, so option B is incorrect. Discontinuing therapy for a rash is not advisable as it may worsen the hyperbilirubinemia, making option D incorrect.
Question 3 of 5
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
Correct Answer: A
Rationale: The correct answer is A: Substernal retractions. Substernal retractions in a 16-hour-old newborn can indicate respiratory distress, which requires immediate attention. Retractions occur when the skin pulls in between the ribs or under the rib cage with each breath, suggesting difficulty breathing. This finding is crucial to report promptly to the provider to ensure the newborn receives appropriate intervention and support. The other choices are incorrect:
B) Acrocyanosis is a common finding in newborns and is due to immature circulation.
C) Overlapping suture lines are normal in newborns and typically resolve over time.
D) A head circumference of 33 cm is within the normal range for a newborn.
Question 4 of 5
A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Administer the injection into the vastus lateralis muscle. In newborns, the vastus lateralis muscle is the preferred site for intramuscular injections due to its size and relatively lower risk of hitting nerves or blood vessels. This muscle is located on the anterior lateral aspect of the thigh and is recommended for vaccines in infants. Administering the hepatitis B vaccine in this muscle ensures proper absorption and effectiveness of the vaccine.
Choices B, C, and D are incorrect. Massaging the site vigorously can cause discomfort and potential tissue damage. Inserting the needle at a 45° angle may result in subcutaneous rather than intramuscular injection. Using a 21-gauge needle, though commonly used, may not be the most appropriate size for newborns and can cause unnecessary pain.
Question 5 of 5
A nurse is providing teaching to a client who is at 35 weeks of gestation and has a prescription for an amniocentesis. Which of the following client statements indicates an understanding of the teaching?
Correct Answer: A
Rationale:
Correct Answer: A - "I should empty my bladder before the procedure."
Rationale: Emptying the bladder before amniocentesis helps prevent puncturing the bladder during the procedure due to its proximity to the uterus. This statement indicates understanding of the importance of bladder emptying to ensure a safe and successful amniocentesis.
Summary of other choices:
B: Incorrect - Lying on the side is not a key instruction for amniocentesis.
C: Incorrect - Most amniocentesis procedures are performed while the client is awake.
D: Incorrect - Fasting is not necessary for amniocentesis; it is a simple and quick procedure that does not require fasting.