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 action is essential to prevent compression and protect the exposed cord from infection. By covering the umbilical cord with a sterile saline-saturated towel, the nurse can maintain the cord's moisture and integrity, reducing the risk of cord compression and infection. This step is crucial in managing a prolapsed umbilical cord until emergency interventions can be performed.
Summary:
A: Initiating IV fluids is not the priority in this situation as the immediate concern is to protect the umbilical cord.
B: Performing a vaginal examination by applying upward pressure can further compress the cord and worsen the fetal distress.
C: Administering oxygen is important but is not the immediate priority compared to protecting the umbilical cord.
E, F, G: Not applicable.
Question 2 of 5
A nurse is caring for a client who is in the second stage of labor. Which of the following manifestations should the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: The client delivers the newborn. In the second stage of labor, the cervix is fully dilated, and the mother pushes to deliver the baby. This stage ends with the birth of the newborn.
Choice A is incorrect because expelling the placenta occurs in the third stage of labor.
Choice B is incorrect as gradual dilation of the cervix happens in the first stage.
Choice C is incorrect because regular contractions are characteristic of the first stage of labor.
Question 3 of 5
A nurse is caring for a client who is receiving prenatal care and is at her 24-week appointment. Which of the following laboratory tests should the nurse plan to conduct?
Correct Answer: A
Rationale: The correct answer is A: 1-hour glucose tolerance test. At 24 weeks of pregnancy, it is important to screen for gestational diabetes. The 1-hour glucose tolerance test helps in detecting elevated blood sugar levels. It is a routine test to assess the risk of gestational diabetes.
Choice B: Rubella titer is typically done early in pregnancy to check immunity to rubella and is not necessary at 24 weeks.
Choice C: Group B strep culture is usually done around 35-37 weeks gestation to determine if the mother carries group B strep bacteria, not at 24 weeks.
Choice D: Blood type and Rh testing are important in early pregnancy to determine if the mother is Rh-positive or negative and to assess compatibility with the baby's blood type. This test is not specific to 24 weeks.
Therefore, the 1-hour glucose tolerance test is the most relevant test to conduct at the 24-week prenatal appointment.
Question 4 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, high blood sugar level, in gestational diabetes mellitus can lead to osmotic diuresis, causing increased urination (polyuria). This occurs because the kidneys try to eliminate excess glucose from the blood by excreting it in the urine, resulting in increased urine production. Double vision is associated with hyperglycemia in diabetic ketoacidosis, not specifically gestational diabetes. Sweating and dizziness are more commonly related to hypoglycemia, low blood sugar. Hence, the most specific and indicative clinical finding of hyperglycemia in gestational diabetes is increased urination.
Question 5 of 5
A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors paces the client at risk for infection.
Correct Answer: C
Rationale: The correct answer is C: Midline episiotomy. A midline episiotomy is a surgical incision made during childbirth that increases the risk of infection due to the proximity to the anus and rectum. The incision site is more prone to contamination from fecal matter, leading to a higher risk of infection. Placenta previa (
B) is a condition where the placenta partially or fully covers the cervix, which can lead to bleeding but not necessarily infection. Meconium-stained amniotic fluid (
A) can indicate fetal distress but does not directly increase the risk of infection. Prolonged labor (
D) can increase the risk of infection due to prolonged exposure to bacteria, but it is not as direct a risk factor as a midline episiotomy.