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 to receive oxytocin to augment their labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
Correct Answer: A
Rationale: The correct answer is A: Late decelerations. Late decelerations indicate uteroplacental insufficiency, suggesting that the fetus is not receiving enough oxygen. Administering oxytocin in the presence of late decelerations could further compromise fetal oxygenation and lead to fetal distress. It is crucial to report this finding to the provider to ensure the safety of both the mother and the baby.
Choices B, C, and D are incorrect:
B: Moderate variability of the FHR is a reassuring sign indicating a healthy fetal status.
C: Cessation of uterine dilation may signal a potential issue but does not directly contraindicate the initiation of oxytocin.
D: Prolonged active phase of labor may necessitate oxytocin augmentation but does not contraindicate its initiation.
Question 2 of 5
A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Administer the injection into the vastus lateralis muscle. In newborns, the vastus lateralis muscle is the preferred site for intramuscular injections due to its size and relatively lower risk of hitting nerves or blood vessels. This muscle is located on the anterior lateral aspect of the thigh and is recommended for vaccines in infants. Administering the hepatitis B vaccine in this muscle ensures proper absorption and effectiveness of the vaccine.
Choices B, C, and D are incorrect. Massaging the site vigorously can cause discomfort and potential tissue damage. Inserting the needle at a 45° angle may result in subcutaneous rather than intramuscular injection. Using a 21-gauge needle, though commonly used, may not be the most appropriate size for newborns and can cause unnecessary pain.
Question 3 of 5
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Minimal arm recoil. In a premature newborn born at 26 weeks of gestation, minimal arm recoil is expected according to the New Ballard Score. This is because premature infants have immature muscle tone, which leads to reduced arm recoil. This finding is consistent with the developmental stage of a preterm infant.
Other choices are incorrect:
B: Popliteal angle of 90° - This would not be expected in a newborn born at 26 weeks of gestation as their joints would be more flexible.
C: Creases over the entire foot sole - Premature infants may have fewer creases on their soles due to immaturity.
D: Raised areolas with 3 to 4 mm buds - Breast development is not expected in a newborn born at 26 weeks of gestation.
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 assessing a newborn following a forceps-assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of this birth method?
Correct Answer: D
Rationale: The correct answer is D: Facial palsy. Forceps-assisted birth can lead to pressure on the facial nerve, resulting in facial nerve injury and facial palsy in the newborn. This can manifest as weakness or paralysis of facial muscles. Polycythemia (
A) is not typically associated with forceps-assisted birth. Hypoglycemia (
B) may occur due to various reasons but is not directly related to the birth method. Bronchopulmonary dysplasia (
C) is a lung condition often seen in premature infants on long-term ventilation. In summary, facial palsy is a potential complication of forceps-assisted birth due to nerve compression, while the other options are less likely to be directly linked to this birth method.