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. This finding is concerning as it may indicate hyperemesis gravidarum, a severe form of morning sickness that can lead to dehydration and electrolyte imbalances, posing a risk to both the mother and fetus. The weight loss is significant and needs immediate attention from the provider to prevent complications.
B: Reports of mood swings are common in pregnancy due to hormonal changes and are not typically a cause for immediate concern.
C: Nosebleeds occurring approximately 3 times per week are often due to increased blood volume and hormone changes during pregnancy and are not considered a serious issue unless they are severe or frequent.
D: Increased vaginal discharge is a common symptom of pregnancy and is usually not a cause for alarm unless accompanied by other symptoms like itching or a foul odor.
Question 2 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 newborn indicate respiratory distress and can be a sign of a serious issue such as respiratory distress syndrome. This finding requires immediate attention from the provider to assess and manage the newborn's respiratory status. Acrocyanosis (
B) is a common finding in newborns and is not typically concerning. Overlapping suture lines (
C) can be normal in newborns due to molding during birth. A head circumference of 33 cm (13 in) (
D) falls within the normal range for a newborn and does not require immediate reporting.
Question 3 of 5
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
Correct Answer: D
Rationale:
Correct
Answer: D - Respiratory distress
Rationale: Hypoglycemia in a late preterm newborn can lead to respiratory distress due to inadequate glucose supply to the brain, causing dysfunction in respiratory centers. This can manifest as tachypnea, grunting, nasal flaring, and retractions. Hypertonia, increased feeding, and hyperthermia are not specific signs of hypoglycemia in newborns.
Summary:
A: Hypertonia is not a typical manifestation of hypoglycemia in newborns.
B: Increased feeding is more likely to be seen in newborns with hunger cues, not necessarily indicative of hypoglycemia.
C: Hyperthermia is not a common sign of hypoglycemia in newborns.
Question 4 of 5
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
Correct Answer: C
Rationale: The correct answer is C: Assist the client to empty their bladder. Palpating the uterus above the umbilicus 12 hours postpartum indicates uterine displacement due to a full bladder. A distended bladder can displace the uterus, leading to uterine atony and increased risk of postpartum hemorrhage. By assisting the client to empty their bladder, the nurse can help the uterus return to its proper position, reducing the risk of complications. Reassessing the client in 2 hours (
A) does not address the immediate issue of bladder distention. Administering simethicone (
B) is indicated for gas relief and not related to the palpated uterus. Instructing the client to lie on their right side (
D) may be uncomfortable and does not address the underlying bladder distention.
Question 5 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 is important because phototherapy requires direct exposure of the newborn's skin to the light source to effectively reduce bilirubin levels. Clothing can block the light and decrease the effectiveness of the therapy. It is essential to maximize skin exposure during phototherapy.
Choice A is incorrect because feeding water is not directly related to phototherapy for hyperbilirubinemia.
Choice B is incorrect as applying lotion can interfere with the effectiveness of the therapy by creating a barrier between the skin and the light source.
Choice D is incorrect because a rash is a common side effect of phototherapy and does not necessarily require discontinuation of the therapy.