ATI RN
ATI RN Maternal Newborn Latest Update. Questions
Extract:
Question 1 of 5
A nurse is caring for a newborn who has jaundice and a new prescription for phototherapy. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Close the newborn's eyes before applying eyepatches. This is important to protect the newborn's eyes during phototherapy as exposure to bright lights can damage the eyes. Closing the eyes with eyepatches helps prevent potential eye damage. Providing glucose water (
A) is not necessary for phototherapy. Turning the newborn every 4 hours (
B) is a routine nursing intervention but not specific to phototherapy. Applying hydrating lotion (
C) is not recommended as it may interfere with the effectiveness of the phototherapy.
Question 2 of 5
A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position. Which of the following questions should the nurse ask to evaluate the effectiveness of this intervention?
Correct Answer: D
Rationale: The correct answer is D: "Has your back labor improved?" In the occipitoposterior position, the baby's head is pressing against the mother's sacrum, causing intense back pain known as back labor. By asking if the back labor has improved, the nurse can directly assess the effectiveness of the hands-and-knees position in helping relieve the pressure on the sacrum and potentially rotating the baby into a more favorable position. Option A focuses on suprapubic pain, which is not typically associated with occipitoposterior positioning. Option B addresses pelvic pressure, which may not be directly affected by the hands-and-knees position. Option C inquires about contractions, which are not the primary concern in this scenario.
Extract:
A nurse is caring for a client who is experiencing a postpartum hemorrhage and has a new prescription for misoprostol.
Exhibit 2: Medical History
Preeclampsia
Cesarean birth of viable twin male newborns
Question 3 of 5
The nurse is assessing the client 30 min later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
| Findings 30 min later | Unrelated to diagnosis | Indication Of potential improvement | Indication of Potential worsening condition |
|---|---|---|---|
| Fundus at level of umbilicus | |||
| Cloudy urine | |||
| Blood pressure 80/50 mm Hg | |||
| Moderate lochia rubra | |||
| Thready pulse | |||
| Fundus firm to palpation |
Correct Answer:
Rationale: - A, D, E are correct, B, C are incorrect)
Rationale: A - Fundus at level of umbilicus indicates proper uterine involution. D - Moderate lochia rubra is expected postpartum. E - Thready pulse may indicate hypovolemia, requiring intervention. B - Cloudy urine may indicate infection, not improvement. C - Low blood pressure may indicate hypovolemic shock, a worsening condition.
Extract:
Question 4 of 5
A nurse is assessing a client who is 1 hr postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Massage the client's fundus. This is the first action the nurse should take because excessive vaginal bleeding postpartum could indicate uterine atony, which is a common cause of postpartum hemorrhage. Massaging the fundus helps stimulate uterine contractions, which can help control bleeding. This should be done before administering medications like oxytocin (
B) or providing oxygen (
D), as addressing the underlying cause is crucial. Emptying the bladder (
C) is important but comes after addressing the uterine atony.
Question 5 of 5
A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply.)
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D.
A) Labor induction with oxytocin can lead to uterine hyperstimulation, increasing the risk of postpartum hemorrhage.
C) Vacuum-assisted delivery can cause trauma to the birth canal, leading to excessive bleeding.
D) A history of uterine atony indicates a weak uterine muscle tone, which is a significant risk factor for postpartum hemorrhage.
B) Newborn weight and E) history of human papillomavirus are not directly related to postpartum hemorrhage.