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 receiving oxytocin via continuous IV infusion and is experiencing persistent late decelerations in the FHR. After discontinuing the infusion, which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen at 10 L/min via nonrebreather facemask. Late decelerations in fetal heart rate (FHR) indicate uteroplacental insufficiency, possibly due to decreased oxygen supply to the fetus. Providing oxygen via nonrebreather facemask can help increase oxygenation to the mother, subsequently improving oxygen delivery to the fetus. This intervention aims to address the underlying cause of late decelerations and improve fetal oxygenation.
Choice A is incorrect because instructing the client to bear down and push with contractions can further compromise fetal oxygenation.
Choice C is incorrect as placing the client in a supine position can worsen late decelerations by reducing placental perfusion.
Choice D, initiating an amnioinfusion, is not indicated for late decelerations. It is important to prioritize actions that improve oxygenation in this scenario.
Question 2 of 5
A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?
Correct Answer: B
Rationale: The correct answer is B: Transmission can occur via the saliva and urine of the newborn. Cytomegalovirus (CMV) can be transmitted through bodily fluids such as saliva, urine, blood, and breast milk. This is important information for nurses to be aware of as they care for newborns who may be infected.
Explanation for other choices:
A: Mothers do not receive prophylactic treatment with acyclovir for CMV, as there is no specific antiviral treatment for this virus.
C: Lesions on the mother's genitalia are not a typical feature of CMV infection.
D: Airborne precautions are not required for CMV as it is primarily transmitted through bodily fluids, not through the air.
Question 3 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 4 of 5
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on bed rest. This is essential to prevent further clot formation and reduce the risk of embolism. Activity can dislodge the clot and lead to serious complications. Administering aspirin for pain is not appropriate as it can increase the risk of bleeding due to heparin therapy. Massaging the affected leg can also dislodge the clot. Applying cold compresses is not recommended for thrombophlebitis.
Question 5 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.