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 at 10 weeks of gestation. Which of the following findings should the nurse report to the provider?
Correct Answer: A
Rationale: The correct answer is A. Frequent vomiting with weight loss of 3 lb in 1 week is concerning as it may indicate hyperemesis gravidarum, a severe form of morning sickness that can lead to dehydration and electrolyte imbalance, posing risks to both the mother and fetus. The nurse should report this finding to the provider for further evaluation and intervention.
B: Reports of mood swings are common during pregnancy due to hormonal changes and are not typically a cause for concern at this gestational age.
C: Nosebleeds occurring approximately 3 times per week are common in pregnancy due to increased blood volume and nasal congestion and do not typically require immediate provider notification.
D: Increased vaginal discharge is a normal finding in pregnancy due to hormonal changes and increased blood flow to the pelvic area and does not typically necessitate immediate provider notification.
Question 2 of 5
A nurse is reviewing the prescriptions for a client who is pregnant and is taking digoxin. Which of the following actions should the nurse take to best evaluate the client’s medication adherence?
Correct Answer: D
Rationale: The correct answer is D: Check the client’s serum medication level. This is the best way to evaluate medication adherence for digoxin in a pregnant client as it provides an objective measure of the drug concentration in the blood. This is important because digoxin has a narrow therapeutic range and monitoring serum levels helps ensure the drug is at an effective dose without reaching toxic levels, which can be harmful to both the mother and the fetus. Asking the client if they are taking the medication as prescribed (choice
A) relies on self-reporting, which may not always be accurate. Assessing kidney function (choice
B) and determining the apical pulse rate (choice
C) are important aspects of digoxin therapy but do not directly assess medication adherence.
Question 3 of 5
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
Correct Answer: D
Rationale:
Correct Answer: D - Report the client’s condition to the local health department.
Rationale: Reporting the client's HIV positive status to the local health department is crucial for public health surveillance and monitoring. This action helps to prevent the spread of HIV to others and ensures appropriate follow-up care and support for the client. It also allows for contact tracing and identification of potential exposure risks. Additionally, notifying the health department enables them to provide resources and interventions to support the client's health and well-being.
Incorrect
Choices:
A: Administering penicillin G is not the appropriate action for an HIV-positive client at 22 weeks of gestation. Penicillin G is typically used to treat bacterial infections, not HIV.
B: Instructing the client to schedule an annual pelvic examination is important for general health maintenance but is not directly related to the client's HIV status and gestational age.
C: Waiting to start HIV medication until after delivery is not recommended as timely initiation of antiretrov
Question 4 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:
Correct Answer: C - Remove all clothing from the newborn except the diaper.
Rationale: Phototherapy involves exposing the newborn's skin to light to breakdown excess bilirubin.
To maximize the effectiveness of phototherapy, the newborn should have as much skin exposed to the light as possible. Removing all clothing except the diaper ensures that the most surface area is exposed to the light, improving bilirubin breakdown.
Summary of other choices:
A: Feeding water is not directly related to phototherapy for hyperbilirubinemia.
B: Applying lotion does not aid in the effectiveness of phototherapy.
D: Discontinuing therapy due to a rash may compromise the treatment of hyperbilirubinemia.
Question 5 of 5
A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Determine respiratory function. The first priority in an unresponsive client is to assess their airway, breathing, and circulation (ABCs). Respiratory function is crucial for oxygenation and maintaining vital signs. If a client is unresponsive, assessing their respiratory status is essential to determine if they are breathing or in need of immediate intervention like CPR. Increasing IV fluid rate (
B) is not the priority as the client's respiratory status needs to be assessed first. Accessing emergency medications (
C) is not the immediate priority as the client's airway and breathing take precedence. Collecting a blood sample (
D) may be necessary later but is not the first action in an unresponsive client.