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 reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following actions should the nurse take next?
Correct Answer: B
Rationale: The correct answer is B: Cover the umbilical cord with a sterile saline-saturated towel. This action is essential to prevent compression and drying of the umbilical cord, which could lead to fetal hypoxia and compromise fetal circulation. By covering the umbilical cord with a sterile saline-saturated towel, the nurse can protect the cord and maintain fetal perfusion until delivery can be expedited. Performing a vaginal examination (choice
A) could further compress the cord and worsen the situation. Administering oxygen (choice
C) may be beneficial but is not the priority in this urgent situation. Initiating IV fluids (choice
D) is not the immediate priority when fetal bradycardia and umbilical cord prolapse are present.
Question 2 of 5
A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Excessive crying. Neonatal abstinence syndrome is characterized by withdrawal symptoms in newborns due to exposure to drugs in utero. Excessive crying is a common manifestation of this syndrome as the newborn experiences discomfort and agitation. Diminished deep tendon reflexes (
A), decreased muscle tone (
C), and absent Moro reflex (
D) are not typically associated with neonatal abstinence syndrome. These findings may be seen in other conditions, but not specifically in newborns with this syndrome.
Question 3 of 5
A nurse is obtaining a 2-hr postprandial blood glucose from a client. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Select the lateral side of the finger for puncture. This choice is correct because the lateral side of the finger has fewer nerve endings, making it less painful for the client. It also minimizes the risk of injury to the client and provides an adequate blood sample for testing.
Explanation for other choices:
A: Puncturing the finger while still damp with antiseptic solution can dilute the blood sample, leading to inaccurate results.
B: Smearing the blood onto the reagent strip can cause contamination and inaccurate readings.
C: Holding the finger above the heart prior to puncture can lead to increased blood flow and affect the accuracy of the blood glucose reading.
Question 4 of 5
A nurse is assessing a newborn who was born postterm. Which of the following findings should the nurse expect?
Correct Answer: C
Rationale: The correct answer is C: Nails extending over tips of fingers. Postterm newborns have longer nails due to the extended intrauterine period. Large deposits of subcutaneous fat (
A) are common in term and postterm newborns, not specific to postterm. Thin covering of fine hair on shoulders and back (
B) is typical in preterm newborns, not postterm. Pale, translucent skin (
D) is seen in preterm infants, not postterm.
Therefore, the most appropriate finding to expect in a postterm newborn is nails extending over tips of fingers.
Question 5 of 5
A nurse is teaching about car seat safety to the parents of a newborn who was delivered at 38 weeks of gestation. Which of the following statements by a parent indicates an understanding of the teaching?
Correct Answer: C
Rationale: The correct answer is C: The car seat should be positioned in the car at a 45-degree angle. This statement demonstrates understanding because newborns who were born at 38 weeks of gestation may have poor muscle tone and need their car seat reclined at a 45-degree angle to keep their airway open. This position helps prevent the baby's head from falling forward and potentially obstructing their breathing.
Choice A is incorrect because using a sleep sack in a car seat can interfere with the proper fit and function of the harness system.
Choice B is incorrect because a car seat challenge test is typically done for preterm infants to assess their ability to sit safely in a car seat, not for full-term newborns.
Choice D is incorrect because current guidelines recommend keeping infants in a rear-facing car seat until at least 2 years of age, not turning it forward-facing at 1 year old.