RN ATI Maternal Newborn 2023 with NGN -Nurselytic

Correct Answer: C

Rationale: The correct answer is C: Biophysical profile (BPP). At 41 weeks gestation, a positive contraction stress test indicates potential fetal distress. A BPP evaluates fetal well-being through assessing fetal heart rate, fetal movement, fetal breathing, fetal tone, and the amniotic fluid volume. This test helps determine if immediate delivery is necessary.
Incorrect choices:
A: Percutaneous umbilical blood sampling is used to assess fetal blood gases and acid-base status, not specifically for fetal distress assessment.
B: Amnioinfusion is used to replace amniotic fluid during labor, not for evaluating fetal well-being in this context.
D: Chorionic villus sampling is a prenatal test used to diagnose genetic abnormalities, not for assessing fetal well-being.

Correct Answer: B, C, D, E, F

Rationale:
To determine if the assessment findings are consistent with hypoglycemia, hyperbilirubinemia, or sepsis, we analyze each choice.
B: Decreased temperature - Can be seen in hypoglycemia, sepsis, but not hyperbilirubinemia.
C: Lethargy - Common in hypoglycemia, sepsis, less in hyperbilirubinemia.
D: Poor feeding - Indicative of hypoglycemia, sepsis, not hyperbilirubinemia.
E: Respiratory distress - Present in sepsis, less likely in hypoglycemia or hyperbilirubinemia.
F: Yellow sclera and oral mucosa - Suggestive of hyperbilirubinemia.

Therefore, choices B, C, D, E, F are consistent with a range of hypoglycemia, sepsis, and hyperbilirubin

Correct Answer: B

Rationale: The correct answer is B: Verify the newborn's identification. This is the first action the nurse should take because ensuring the correct identification of the newborn is crucial for providing safe and effective care. Incorrect identification can lead to errors in medication administration, treatment, and monitoring. Confirming the newborn's Apgar score (
A) is important for assessing the newborn's initial condition but is not the priority in this situation. Administering vitamin K (
C) is essential for newborns but can be done after verifying identification. Determining obstetrical risk factors (
D) is important for understanding the newborn's medical history but is not the immediate priority.

Correct Answer: A

Rationale: The correct answer is A: Swelling of the face. This finding could indicate a serious condition called preeclampsia, which is characterized by high blood pressure and protein in urine. Preeclampsia can be life-threatening to both the mother and baby if not managed promptly. Swelling of the face is a key symptom of preeclampsia and must be reported to the provider immediately for further assessment and intervention. The other choices (B: Varicose veins in the calves, C: Nonpitting 1+ ankle edema, D: Hyperpigmentation of the cheeks) are common discomforts in pregnancy and not typically concerning at this stage. They do not pose immediate risks to the client's health or require urgent intervention.

Correct Answer: A

Rationale: The correct answer is A. Substernal retractions in a 16-hour-old newborn indicate respiratory distress and may be a sign of an underlying issue such as respiratory distress syndrome. This finding requires immediate attention from the healthcare provider to assess and manage the newborn's respiratory status.



Choices B, C, and D are not as concerning in a newborn of this age. Acrocyanosis is a common finding in newborns due to immature circulation. Overlapping suture lines can be normal due to the molding process during birth. A head circumference of 33 cm falls within the normal range for a newborn.
Therefore, these findings do not require immediate reporting to the provider.