ATI RN
ATI RN Maternal Newborn level 3 Final Exam 2023 Questions
Extract:
Question 1 of 5
A nurse is caring for a newborn Boys 6 hours old and has a bedside glucose meter reading of 65 mg / DL. The New Orleans mother has Type 2 diabetes mellitus. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Feed the newborn immediately. In this scenario, the newborn's blood glucose level is 65 mg/dL, which is considered low. Given that the mother has Type 2 diabetes, the baby is at risk for hypoglycemia due to maternal hyperglycemia during pregnancy. Feeding the newborn immediately will help increase their blood glucose levels. IV dextrose solution administration (choice
A) is not necessary at this time as the baby can be orally fed. Obtaining a blood sample for serum glucose level (choice
B) can be done later after feeding to confirm improvement. Reassessing blood glucose prior to the next feeding (choice
C) delays necessary intervention. The baby must be fed promptly to prevent further hypoglycemia.
Question 2 of 5
A nurse is caring for four enter-partum clients. Which of the following clients should the nurse assess first?
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client at 32 weeks of gestation reporting seeing floating spots first because it could indicate a serious condition called preeclampsia, characterized by high blood pressure and organ damage. This client's symptom is a sign of visual disturbances, a classic symptom of preeclampsia. Immediate assessment is necessary to prevent complications such as seizures and stroke. The other clients' symptoms, urinary frequency, leg cramps, and periodic numbness in fingers, are common discomforts in pregnancy but do not suggest immediate serious complications like preeclampsia.
Question 3 of 5
A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions Should the nurse include in the plan of care?
Correct Answer: B
Rationale: The correct answer is B: Bathe the newborn before initiating skin to skin contact. This action is crucial to reduce the risk of HIV transmission from the mother to the newborn. By bathing the newborn before skin-to-skin contact, the nurse can remove any potential HIV-infected fluids from the baby's skin, reducing the risk of transmission. This step helps to protect the newborn while still allowing for important bonding through skin-to-skin contact after bathing.
Choice A is incorrect as the use of a fetal scalp electrode during labor and delivery is unrelated to preventing HIV transmission from mother to newborn.
Choice C is incorrect as stopping antiretroviral medication can significantly increase the risk of HIV transmission to the newborn.
Choice D is incorrect as administering pneumococcal immunization is important but not within 4 hours following birth in the context of preventing HIV transmission.
Question 4 of 5
A nurse is caring for a client who has placenta previa. Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Painless, vaginal bleeding. Placenta previa is a condition where the placenta partially or completely covers the cervix, leading to painless, bright red bleeding in the third trimester. This occurs because the placenta is located close to or over the cervical opening, causing it to bleed with minimal trauma. It is important for the nurse to recognize this sign as it can lead to maternal and fetal complications if not managed promptly.
Choices A, C, and D are incorrect because they do not align with the typical presentation of placenta previa. A firm rigid abdomen is more indicative of a condition like placental abruption. Uterine hypertonicity is not a common finding in placenta previa. Persistent headache is not a characteristic symptom of placenta previa and may be indicative of other conditions like preeclampsia.
Question 5 of 5
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lap. Which of the following actions should the nurse include?
Correct Answer: C
Rationale: The correct answer is C: Ensure the newborn's eyes are closed beneath the shield. This is crucial during phototherapy to protect the newborn's eyes from potential damage caused by the bright lights. Newborns undergoing phototherapy should have their eyes shielded with protective eye coverings to prevent eye damage.
Choice A is incorrect as lotion can intensify the effects of phototherapy.
Choice B is incorrect as the newborn should be undressed to maximize skin exposure.
Choice D is incorrect as glucose water is not indicated for phototherapy and may interfere with treatment.