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 37 weeks of gestation and is being tested for group B streptococcus ß-hemolytic (GBS). The client is multigravida and multipara with no history of GBS. She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the following is an appropriate response by the nurse?
Correct Answer: D
Rationale: The correct answer is D: We need to know if you are positive for GBS at the time of delivery. At 37 weeks gestation, testing for GBS is important as the status can change. GBS colonization can come and go, so testing closer to delivery ensures the most accurate result to guide antibiotic prophylaxis during labor to prevent transmission to the newborn.
Choices A, B, and C are incorrect because they focus on past history or symptoms, which do not indicate the current GBS status. Testing closer to delivery is crucial to prevent neonatal GBS infection.
Question 2 of 5
A nurse is preparing to administer an IM injection to a newborn. Which of the following sites should the nurse select?
Correct Answer: A
Rationale: The correct site for an IM injection in a newborn is the vastus lateralis muscle. This site is recommended for infants due to the larger muscle mass, reduced risk of injury to nerves and blood vessels, and better absorption of the medication. The vastus lateralis is located on the lateral aspect of the thigh and is easily accessible for injections. In contrast, the dorsogluteal site is not recommended in infants due to the proximity of the sciatic nerve and the risk of injury. The deltoid muscle is typically used for older children and adults, not newborns. The rectus femoris muscle is not a commonly used site for IM injections in newborns. Selecting the vastus lateralis ensures safe and effective administration of the medication.
Question 3 of 5
A nurse is reviewing laboratory findings for a client who is at 20 weeks of gestation. Which of the following findings should the nurse report to the provider?
Correct Answer: D
Rationale: The correct answer is D: Fasting blood glucose 180 mg/dL (74 to 106 mg/dL). During pregnancy, there is an increased risk of gestational diabetes, where blood glucose levels may become elevated. A fasting blood glucose level of 180 mg/dL is significantly higher than the normal range of 74 to 106 mg/dL, indicating hyperglycemia. High blood glucose levels can have adverse effects on both the mother and the developing fetus, such as macrosomia (large birth weight), birth complications, and potential long-term health risks.
Therefore, the nurse should report this finding to the provider promptly for further evaluation and management.
Incorrect choices:
A: Hematocrit within the range is normal during pregnancy.
B: Creatinine within the range is normal and indicates normal kidney function.
C: WBC count slightly elevated is common during pregnancy due to physiological changes.
Question 4 of 5
A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include?
Correct Answer: D
Rationale:
Rationale: Option D is correct because pressing the handheld button when feeling the baby move during the nonstress test helps to record fetal movements and heart rate changes. This action ensures accurate monitoring of the baby's well-being. Option A is incorrect because the duration of the test can vary and is not necessarily limited to 10-15 minutes. Option B is incorrect as pregnant clients should not lie in a supine position for extended periods due to the risk of supine hypotensive syndrome. Option C is incorrect as fasting is not necessary for a nonstress test.
Question 5 of 5
A nurse is caring for a newborn immediately following birth. For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?
Correct Answer: D
Rationale: The correct answer is D:
To facilitate bonding between the newborn and parent. Delaying the instillation of antibiotic ophthalmic ointment allows for uninterrupted skin-to-skin contact and bonding between the newborn and parent, which is crucial for establishing a strong emotional connection and promoting breastfeeding. This initial bonding period is a critical time for the newborn's emotional and psychological development.
Choices A, B, and C are incorrect because immediate instillation of the ointment is essential to prevent neonatal conjunctivitis, regardless of the newborn's weight, mode of delivery, or the need to identify infection manifestations.