ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 of 5
A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Verify the newborn's identification. This is the first action the nurse should take because ensuring the correct identification of the newborn is crucial for providing safe and effective care. Without proper identification, there is a risk of administering medications or treatments to the wrong newborn. Confirming the newborn's Apgar score can be important but is not as time-sensitive as verifying identification. Administering vitamin K and determining obstetrical risk factors are important tasks but should come after verifying the newborn's identification to ensure the safety of the care provided.
Question 2 of 5
A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Determine respiratory function. The first priority in an unresponsive client is to assess their airway, breathing, and circulation (ABCs). Respiratory function is crucial for oxygenation and maintaining vital signs. If a client is unresponsive, assessing their respiratory status is essential to determine if they are breathing or in need of immediate intervention like CPR. Increasing IV fluid rate (
B) is not the priority as the client's respiratory status needs to be assessed first. Accessing emergency medications (
C) is not the immediate priority as the client's airway and breathing take precedence. Collecting a blood sample (
D) may be necessary later but is not the first action in an unresponsive client.
Question 3 of 5
A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: Monitor the client’s blood pressure every 5 min following the first dose of anesthetic solution. Monitoring blood pressure is crucial after administering epidural anesthesia to detect any potential hypotension, a common side effect. Regular monitoring allows for prompt intervention if hypotension occurs, ensuring the client's safety.
Choices A, B, and D are incorrect:
A: Placing the client in a supine position for 30 min following the first dose of anesthetic can lead to hypotension due to venous pooling in this position.
B: Administering dextrose 5% in water is not indicated for epidural anesthesia and does not address the need for blood pressure monitoring.
D: NPO status is not directly related to the need for blood pressure monitoring post-epidural administration.
Question 4 of 5
A nurse is caring for a client who is at 10 weeks of gestation. Which of the following findings should the nurse report to the provider?
Correct Answer: A
Rationale: The correct answer is A because frequent vomiting with significant weight loss in a short period can indicate hyperemesis gravidarum, a severe form of nausea and vomiting in pregnancy. This condition can lead to dehydration and electrolyte imbalances, posing risks to both the mother and the fetus. The weight loss of 3 lb in a week is concerning and requires immediate medical attention to prevent complications. The other choices (B, C,
D) are common discomforts during pregnancy and not considered urgent issues that require immediate reporting to the provider. Mood swings (
B) are a normal part of hormonal changes in pregnancy, nosebleeds (
C) can be due to increased blood volume and nasal congestion, and increased vaginal discharge (
D) is a common physiological change in pregnancy.
Question 5 of 5
A nurse is caring for a client who is at 36 weeks of gestation and has methicillin-resistant Staphylococcus aureus. Which of the following types of isolation precautions should the nurse initiate?
Correct Answer: B
Rationale: The correct answer is B: Contact precautions. Methicillin-resistant Staphylococcus aureus (MRS
A) is typically spread through direct contact with an infected person or contaminated surfaces.
Therefore, the nurse should implement contact precautions to prevent the transmission of the bacteria. This includes wearing gloves and gowns when entering the client's room, ensuring proper hand hygiene, and using dedicated patient care equipment. Droplet precautions (choice
A) are used for pathogens spread via respiratory droplets, such as influenza. Protective environment (choice
C) is used for immunocompromised clients to protect them from environmental pathogens. Airborne precautions (choice
D) are for pathogens that remain suspended in the air, like tuberculosis.