ATI RN
ATI RN Maternal Newborn Latest Update. Questions
Extract:
Question 1 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?" In the occipitoposterior position, the baby's head is pressing against the mother's sacrum, causing intense back pain known as back labor. By asking if the back labor has improved, the nurse can directly assess the effectiveness of the hands-and-knees position in helping relieve the pressure on the sacrum and potentially rotating the baby into a more favorable position. Option A focuses on suprapubic pain, which is not typically associated with occipitoposterior positioning. Option B addresses pelvic pressure, which may not be directly affected by the hands-and-knees position. Option C inquires about contractions, which are not the primary concern in this scenario.
Question 2 of 5
A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?
Correct Answer: D
Rationale: The correct answer is D: Jitteriness. Infants born to mothers with gestational diabetes are at risk for hypoglycemia due to hyperinsulinemia. Jitteriness is a common manifestation of hypoglycemia in newborns. It occurs due to the brain's response to low glucose levels, leading to neurologic symptoms. Abdominal distention (
A) is not typically associated with hypoglycemia in newborns. Petechiae (
B) are tiny red spots due to bleeding under the skin and are not related to hypoglycemia. Increased muscle tone (
C) is not a typical manifestation of hypoglycemia in newborns.
Extract:
A nurse is assessing a postpartum client who delivered vaginally 8 hr ago.
Exhibit 1 - Nurses' Notes: 0700
Breasts soft, nipples intact. Uterus palpated firm, midline, and at the level of the umbilicus.
Moderate amount of lochia rubra. Episiotomy site well approximated with mild edema and
ecchymosis. Client reports pain as 2 on a scale of 0 to 10. Able to void spontaneously; no bladder
distention. Deep tendon reflexes 1+. Peripheral edema 2+ in bilateral lower extremities.
Exhibit 2 - Nurses' Notes: 1100
Breasts soft, nipples intact. Uterus palpated soft with lateral deviation and 1 cm above the
umbilicus. Large amount of lochia rubra. Episiotomy site well approximated with mild edema
and ecchymosis. Client reports pain as 3 on a scale of 0 to 10. Deep tendon reflexes 1+.
Peripheral edema 2+ in bilateral lower extremities.
Question 3 of 5
Select the 3 findings that require immediate follow-up.
Correct Answer: A,B,C
Rationale: The correct answer is A, B, and C because they indicate potential health concerns that require immediate follow-up. A, lateral deviation of the uterus, could indicate a possible uterine abnormality or displacement. B, deep tendon reflexes 1+, may suggest neurological issues or abnormalities. C, pain rating of 3 on a scale of 0 to 10 (increased), signifies escalating pain levels that need to be addressed promptly.
Choices D, E, F, and G do not require immediate follow-up as they are within normal ranges or not indicative of urgent issues.
Extract:
Question 4 of 5
A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase intake of vitamin B12. Which of the following foods should the nurse recommend?
Correct Answer: A
Rationale: The correct answer is A: Fortified soy milk. Fortified soy milk is a good source of vitamin B12, which is essential for individuals following a vegan diet as it is mainly found in animal products. Raw carrots, fresh citrus fruits, and brown rice do not contain vitamin B12. The rationale is to recommend fortified soy milk to ensure the client meets their vitamin B12 needs.
Question 5 of 5
A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Administer 500 mL lactated Ringer’s IV bolus. This action is necessary to address the ongoing vaginal bleeding, as it suggests hypovolemia. Administering IV fluids will help restore blood volume and stabilize the client's condition.
Choice A is incorrect because replacing the surgical dressing does not address the underlying cause of the bleeding.
Choice B, evaluating urinary output, may be important but is not the priority in this situation.
Choice C, applying an ice pack to the incision site, is not appropriate for controlling post-cesarean bleeding.