ATI RN
ATI RN Maternal Newborn level 3 Final Exam 2023 (All Correct Answers). Maternal-Child Nursing Questions
Extract:
Question 1 of 5
A nurse is caring for a client who reports spontaneous rupture. The nurse observed fetal bradycardia in the FHR tracing and notices the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following should the nurse take next?
Correct Answer: D
Rationale: The correct answer is D: Cover the umbilical cord with sterile saline saturated towel. This step is crucial to prevent compression of the umbilical cord and maintain blood flow to the fetus, reducing the risk of fetal distress. It also helps in preventing infection and protecting the exposed cord.
Choice A: Initiating an infusion of IV fluids is not the priority in this situation as the immediate concern is to protect the umbilical cord and ensure fetal well-being.
Choice B: Performing a vaginal examination could further worsen the situation by putting pressure on the umbilical cord, leading to decreased blood flow to the fetus.
Choice C: Administering oxygen is important in fetal distress, but covering the umbilical cord takes precedence in this case to prevent further complications.
In summary, covering the umbilical cord with a sterile saline-saturated towel is the correct action to protect the cord and maintain fetal perfusion.
Question 2 of 5
A nurse is caring for a client who has gestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse the client has hyperglycemia?
Correct Answer: B
Rationale: The correct answer is B: Increased urination. Hyperglycemia in gestational diabetes mellitus leads to elevated blood glucose levels, causing the kidneys to filter excess glucose into the urine, leading to increased urination (polyuria). This is due to the osmotic effect of glucose drawing water from the body into the urine. Double vision (choice
A) is more indicative of neurological issues. Sweating (choice
C) can be a response to hypoglycemia rather than hyperglycemia. Dizziness (choice
D) can be a symptom of both hyperglycemia and hypoglycemia, but it is not specific to hyperglycemia.
Question 3 of 5
A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements by the parent indicates an understanding of the teaching?
Correct Answer: A
Rationale: The correct answer is A because positioning the baby's car seat at a 45-degree angle helps prevent the baby's head from slumping forward, ensuring proper airway and breathing. Placing the car seat rear facing until 12 months old is recommended for optimal safety. Option C is incorrect as the harness should be at or below the baby's shoulders. Option D is incorrect as the retainer clip should be positioned at armpit level for proper safety.
Question 4 of 5
A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care?
Correct Answer: B
Rationale: The correct answer is B: Avoid using lotion or ointment on the newborn skin. This is because lotions or ointments can interfere with the effectiveness of phototherapy by blocking the light from reaching the skin. Dressing the newborn in lightweight clothing (
Choice
A) is important to maximize skin exposure to the light. Keeping the newborn supine throughout treatment (
Choice
C) is not directly related to the effectiveness of phototherapy. Measuring the newborn's temperature every 8 hours (
Choice
D) is important but not specifically related to phototherapy.
Question 5 of 5
A nurse is providing discharge instructions to a client who is breastfeeding her newborn.
Correct Answer: B
Rationale: The correct answer is B: Allow the baby to feed at least every 3 hours. This is important for maintaining the baby's hydration, ensuring proper nutrition, and promoting successful breastfeeding. Feeding on demand helps establish a good milk supply and supports the baby's growth and development. Offering water (choice
C) is unnecessary and can interfere with breastfeeding. Limiting feeding time to 5-10 minutes per breast (choice
D) can prevent the baby from getting enough hindmilk, which is rich in fat and important for weight gain. Expecting 2-4 wet diapers every 24 hours (choice
A) is a general guideline but not as crucial as ensuring frequent feedings for a breastfeeding newborn.