ATI RN
ATI RN Maternal Newborn level 3 Final Exam 2023 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is receiving oxytocin to induce labor. The nurse should discontinue the oxytocin if which of the following occurs?
Correct Answer: C
Rationale: The correct answer is C: 6 contractions in 10 minutes. This indicates hyperstimulation of the uterus, putting the fetus at risk. Discontinuing oxytocin is necessary to prevent uterine tachysystole. Contractions lasting 60 seconds (choice
A) are normal. Non-repetitive early decelerations (choice
B) are benign. Moderate variability of the fetal heart rate (choice
D) is a reassuring sign of fetal well-being.
Question 2 of 5
A nurse is caring for a client who is 36 weeks gestation and has MRSA. Which of the following isolation precautions should the nurse initiate?
Correct Answer: B
Rationale: The correct answer is B: Contact precautions. MRSA is primarily spread through direct contact with an infected person or contaminated surfaces. By implementing contact precautions, the nurse can prevent the transmission of MRSA to other patients or healthcare workers. Droplet precautions (choice
A) are used for diseases spread via respiratory droplets, such as influenza. Airborne precautions (choice
C) are for diseases transmitted through small particles in the air, like tuberculosis. Protective environment (choice
D) is used for immunocompromised patients to protect them from environmental pathogens. In this scenario, contact precautions are the most appropriate choice to prevent the spread of MRSA.
Question 3 of 5
A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include?
Correct Answer: B
Rationale:
Correct Answer: B - Allow the baby to feed at least every 3 hours.
Rationale:
1. Breastfeeding frequency is crucial for establishing a good milk supply and ensuring the baby receives adequate nutrition.
2. Newborns typically need to breastfeed at least 8-12 times in 24 hours to meet their nutritional needs.
3. Feeding every 3 hours helps maintain the baby's hydration, energy levels, and growth.
4. Regular feeding also helps prevent issues like engorgement for the mother and ensures the baby gets enough hindmilk for proper growth.
Summary of Incorrect
Choices:
A: Wet diapers may vary, but newborns should ideally have 8-12 wet diapers a day.
C: Offering water between feedings is unnecessary and may fill up the baby's stomach, reducing milk intake.
D: Limiting feeding time per breast may not allow the baby to get enough hindmilk, essential for growth and development.
Question 4 of 5
A nurse is planning care immediately following birth for a newborn who has Myelomeningocele that is 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 in preventing infection in a newborn with myelomeningocele where the spinal cord is exposed. Infection can lead to serious complications. Administering broad-spectrum antibiotics helps to reduce the risk of infection. Cleansing the site with Povidone iodine (choice
B) is important, but antibiotics are necessary for prophylaxis. Monitoring rectal temperature (choice
C) is not directly related to preventing infection. Surgical closure (choice
D) after 72 hours is important, but antibiotics are essential immediately post-birth to prevent infection.
Question 5 of 5
A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions Should the nurse include in the plan of care?
Correct Answer: B
Rationale: The correct answer is B: Bathe the newborn before initiating skin to skin contact. This action is crucial to reduce the risk of HIV transmission from the mother to the newborn. By bathing the newborn before skin-to-skin contact, the nurse can remove any potential HIV-infected fluids from the baby's skin, reducing the risk of transmission. This step helps to protect the newborn while still allowing for important bonding through skin-to-skin contact after bathing.
Choice A is incorrect as the use of a fetal scalp electrode during labor and delivery is unrelated to preventing HIV transmission from mother to newborn.
Choice C is incorrect as stopping antiretroviral medication can significantly increase the risk of HIV transmission to the newborn.
Choice D is incorrect as administering pneumococcal immunization is important but not within 4 hours following birth in the context of preventing HIV transmission.