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 36 weeks of gestation and has methicillin-resistant Staphylococcus aureus. Which of the following types of isolation precautions should the nurse initiate?
Correct Answer: B
Rationale: The correct answer is B: Contact precautions. Methicillin-resistant Staphylococcus aureus (MRS
A) is typically spread through direct contact with an infected person or contaminated surfaces.
Therefore, the nurse should implement contact precautions to prevent the transmission of the bacteria. This includes wearing gloves and gowns when entering the client's room, ensuring proper hand hygiene, and using dedicated patient care equipment. Droplet precautions (choice
A) are used for pathogens spread via respiratory droplets, such as influenza. Protective environment (choice
C) is used for immunocompromised clients to protect them from environmental pathogens. Airborne precautions (choice
D) are for pathogens that remain suspended in the air, like tuberculosis.
Question 2 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 3 of 5
A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position. Which of the following questions should the nurse ask to evaluate the effectiveness of this intervention?
Correct Answer: D
Rationale: The correct answer is D: "Has your back labor improved?" This question is relevant because the occipitoposterior position can cause intense back pain during labor. By asking if the back pain has improved, the nurse can assess the effectiveness of the hands-and-knees position in helping to alleviate this specific discomfort.
Choice A: "Does that lessen your suprapubic pain?" is incorrect because the hands-and-knees position is not specifically targeted at suprapubic pain.
Choice B: "Are you feeling relief from your pelvic pressure?" is incorrect because the hands-and-knees position is more effective for back pain relief rather than pelvic pressure.
Choice C: "Do your contractions feel further apart?" is incorrect because the position change may not directly affect the frequency of contractions.
In summary, the correct question (
D) focuses on the specific issue of back labor associated with occipitoposterior position, making it the most relevant evaluation of the intervention.
Question 4 of 5
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
Correct Answer: D
Rationale: The correct answer is D: Respiratory distress. Hypoglycemia in late preterm newborns can present with signs such as respiratory distress due to inadequate glucose supply to the brain, leading to central nervous system dysfunction. Hypertonia (choice
A) is not a typical sign of hypoglycemia. Increased feeding (choice
B) is a compensatory mechanism to raise blood glucose levels. Hyperthermia (choice
C) is not directly related to hypoglycemia.
Therefore, choice D is the most indicative of hypoglycemia in this scenario.
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:
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.