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 crucial to prevent umbilical cord compression, maintain blood flow to the fetus, and reduce the risk of hypoxia. By covering the umbilical cord with a sterile saline-saturated towel, the nurse can protect the cord from further compression and potential infection. Performing a vaginal examination (choice
A) could worsen the situation by causing more cord compression. Administering oxygen (choice
C) is important but covering the cord takes priority. Initiating IV fluids (choice
D) is not the immediate priority in this emergency situation.
Question 2 of 5
A nurse is admitting a client to the labor and delivery unit when the client states, 'My water just broke.' Which of the following interventions is the nurse's priority?
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. This is the priority intervention because assessing the fetal heart rate (FHR) is crucial to ensuring the well-being of the fetus after the client's water has broken. Monitoring the FHR can help detect any signs of distress or complications that may arise. Performing Nitrazine testing (
A) and assessing the fluid (
B) can provide additional information, but monitoring the FHR takes precedence due to its direct impact on fetal well-being. Checking cervical dilation (
C) is important but not as urgent as monitoring the FHR in this situation.
Question 3 of 5
A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client’s history should the nurse recognize as a contraindication to oral contraceptives? (Select all that apply.)
Correct Answer: A, B, D
Rationale: The correct answers are A, B, and D. Cholecystitis is a contraindication due to increased risk of gallbladder disease. Hypertension is a contraindication as it can be exacerbated by oral contraceptives. Migraine headaches with aura are a contraindication due to increased risk of stroke. Human papillomavirus is not a contraindication.
Extract:
A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hr old.
Physical Examination:
• Fontanels soft and flat
• Head molded with caput succedaneum
• Eyes symmetric, no discharge, sclera yellow
• Mucous membranes dry
• Abdomen soft and rounded, bowel sounds present x 4 quadrants
Question 4 of 5
Which of the following findings should the nurse report to the provider? (Select all that apply.)
Correct Answer: A,B,C,G
Rationale: The correct answer is A, B, C, and G.
A: Coombs test result is important for assessing for hemolytic anemia.
B: Mucous membrane assessment can indicate hydration status and oxygenation.
C: Intake and output are crucial for assessing fluid balance.
G: Sclera color can indicate liver function or jaundice.
Other choices are incorrect because:
D: Respiratory rate is important, but not typically a priority to report unless abnormal.
E: Head assessment finding is broad and does not specify a critical finding.
F: Heart rate is important, but not as critical as the other choices.
Extract:
A nurse is caring for a newborn.
Exhibit 1
Medical History
1600:
Apgar score 9 at 1 min and 9 at 5 min
Birth weight 4,706 g (10 lb 6 oz)
Gestational age 40 weeks
Difficult vaginal birth with shoulder dystocia. Exhibit 2
Nurses' Notes
1700:
Newborn is active and moves all extremities except for right arm. No spontaneous movement of
the right arm noted. Right arm remains at side during Moro reflex. Exhibit 3
Physical Examination
1830:
Absent Moro reflex noted in right arm.
Right shoulder and arm are internally rotated and adducted. Elbow extended. Forearm pronated
with wrist and fingers flexed. Diagnosis: Brachial plexus injury resulting in Erb-Duchenne (Erb's
palsy) paralysis.
Question 5 of 5
Which of the following actions should the nurse plan to implement? For each potential nursing action, click to specify if the intervention is indicated or contraindicated for the newborn.
| Potential Nursing Action | Indicated | Contraindicated |
|---|---|---|
| Educate the parents to begin range of motion exercises on the affected arm after 1 week. | ||
| Assess for grasp reflex in the affected extremity. | ||
| Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt. | ||
| Instruct parents to limit physical handling for 2 weeks. |
Correct Answer:
Rationale: [
,
(0, 1, 1),
(0, 0, 1),
(0, 1, 0)
]
Correct Answer: (
B) Assess for grasp reflex in the affected extremity.
Rationale: Assessing for grasp reflex is indicated to evaluate neurological function and response in the affected extremity. Range of motion exercises (
A) are contraindicated as they may exacerbate the condition. Immobilizing the arm (
C) can hinder normal movement and development. Limiting physical handling (
D) may impede bonding and care interactions.