ATI RN
ATI RN maternal newborn 2019 with NGN Exam 2 Questions
Extract:
A newborn who is 1 hour old, respiratory rate 50/min, heart rate 130/min, axillary temperature 36.1°C (97°F)
Question 1 of 5
A nurse is caring for a newborn who is 1 hour old and has a respiratory rate of 50/min, a heart rate of 130/min, and an axillary temperature of 36.1°C (97°F). Which of the following actions should the nurse take?
Correct Answer: D
Rationale: Applying a cap prevents heat loss from the head, addressing the risk of hypothermia at 36.1°C. Bathing increases heat loss, repositioning is insufficient, and oxygen saturation isn't directly related to temperature.
Extract:
A client who is at 12 weeks of gestation
Question 2 of 5
A nurse is assessing a client who is at 12 weeks of gestation. The nurse should report which of the following findings to the provider as an indication of an imminent spontaneous abortion?
Correct Answer: A
Rationale: A dilated cervix indicates that abortion is inevitable. Slight abdominal cramps and scant bright red spotting are common in early pregnancy and not necessarily indicative of miscarriage unless severe or heavy. Elevated hCG is normal in early pregnancy and does not suggest an imminent spontaneous abortion.
Extract:
A term newborn in the supine position
Question 3 of 5
A nurse is assessing the reflexes of a term newborn. After placing the newborn in the supine position, which of the following methods should the nurse use to elicit the Moro reflex?
Correct Answer: C
Rationale: The Moro reflex is elicited by a sudden loud noise, causing the newborn to abduct and then adduct their arms. Turning the head elicits the tonic neck reflex, touching the cheek triggers the rooting reflex, and tapping the forehead induces the glabellar reflex.
Extract:
A client who has bladder distention following a vaginal birth
Question 4 of 5
A nurse is caring for a client who has bladder distention following a vaginal birth. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: Assisting to the bathroom is the least invasive first step to relieve bladder distention. Catheterization is invasive, warm water may not ensure emptying, and sitz baths address perineal healing, not distention.
Extract:
A client who had a vaginal delivery 3 hr ago
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,D,E
Rationale: History of uterine atony, labor induction with oxytocin, and vacuum-assisted delivery increase the risk of postpartum hemorrhage due to uterine fatigue or trauma. Human papillomavirus does not affect uterine bleeding risk, and a newborn weight of 2.948 kg is normal and not a risk factor.