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 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 2 of 5
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?
Correct Answer: D
Rationale: The correct answer is D: Instruct the client to press the provided button each time fetal movement is detected. This action is crucial during a nonstress test, as pressing the button when fetal movement is felt helps to correlate fetal heart rate changes with fetal movement, providing valuable information about the baby's well-being. This allows healthcare providers to assess the baby's response to movement and determine if the fetal heart rate is within normal parameters.
Maintaining the client NPO (
Choice
A) is not necessary for a nonstress test. Placing the client in a supine position (
Choice
B) can decrease blood flow to the fetus and is contraindicated during pregnancy. Instructing the client to massage the abdomen (
Choice
C) may not be appropriate as it could potentially interfere with the test results by causing fetal movement that is not spontaneous.
Extract:
“A nurse on an antepartum unit is caring for a client.
Exhibit1:
Nurses' Notes 0900:Client reports a small amount of bright red blood in their underwear upon
awakening. Client denies contractions or abdominal pain. External fetal monitor applied.
0930:Client passed large amount of bright red blood from vagina.
Denies pain Uterine tone soft and nontender to palpation.
contraction pattern, no contractions noted.
Fetal heart rate pattern: Fetal heart rate baseline 135/min.
Moderate variability. No decelerations noted.
Exhibit2:
Vital Signs 0900: Temperature 36.2°C (97.2° F) Pulse rate 78/min Respiratory rate 20/min Blood pressure
112/64 mm Hg Fetal heart rate 132/min Pulse rate 82/min Blood pressure 116/60 mm Hg Fetal heart
rate 160/min
Exhibit3:
Medical History. G4P3 30 weeks gestation Previous pregnancies delivered via cesarean section
Question 3 of 5
Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify it the intervention is indicated or contraindicated for the client.
| Potential Nursing Action | Indicated | Contraindicated | |
|---|---|---|---|
| Insert a large bore intravenous catheter. | |||
| Assess cervical dilation. | |||
| Weigh perineal pads. | |||
| Administer methotrexate. |
Correct Answer: A, C
Rationale: [1, 0, 1]
Inserting a large bore intravenous catheter is indicated for the client to establish a rapid intravenous access for fluid resuscitation or medication administration. Weighing perineal pads (
C) is important to monitor postpartum blood loss. Assessing cervical dilation (
B) is not indicated as it is not relevant in this scenario. Administering methotrexate (
D) is contraindicated as it is a medication used for medical abortions and is not applicable in this context.
Extract:
Question 4 of 5
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?
Correct Answer: A
Rationale: The correct answer is A: Administer broad-spectrum antibiotics. This is crucial to prevent infection in the exposed neural tissue. Myelomeningocele increases the risk of meningitis due to the breach in the protective layers of the spinal cord. Administering antibiotics helps to prevent bacterial invasion and subsequent infection. Monitoring rectal temperature is not directly related to the myelomeningocele issue. Cleaning the site with povidone-iodine may cause further irritation to the exposed tissue. Immediate surgical closure is usually necessary to prevent infection; waiting 72 hours is not appropriate in this case.
Question 5 of 5
A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
Correct Answer: B
Rationale: The correct answer is B: Temperature. During an amniotomy, there is a risk of infection due to the introduction of bacteria into the amniotic cavity. Monitoring the client's temperature is crucial to identify any signs of infection promptly. Elevated temperature can indicate infection, which can lead to serious complications for both the client and the baby. O2 saturation, blood pressure, and urinary output are important assessments but are not the priority in this situation. Monitoring temperature will help the nurse detect early signs of infection and initiate appropriate interventions.