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 should be the first action taken because ensuring the correct identification of the newborn is crucial for providing appropriate care. Incorrect identification could lead to serious consequences, such as administering medications or treatments to the wrong infant. Confirming the newborn's Apgar score (choice
A) or administering vitamin K (choice
C) can wait until the identification is verified. Determining obstetrical risk factors (choice
D) is important but not the immediate priority.
Question 2 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. This is crucial because epidural anesthesia can cause hypotension, a common side effect. Monitoring the client's blood pressure closely allows for early detection of hypotension and prompt intervention to prevent potential complications like fetal distress. Placing the client in a supine position for 30 min (
A) is incorrect as it can lead to hypotension; administering dextrose solution (
B) is not necessary for epidural anesthesia; ensuring NPO status (
D) is important for other procedures but not specifically for epidural anesthesia.
Question 3 of 5
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?
Correct Answer: B
Rationale: The correct answer is B: Chin quivering. Chin quivering is a common sign of pain in newborns. It indicates discomfort and distress. Decreased heart rate (choice
A), pinpoint pupils (choice
C), and slowed respirations (choice
D) are not typical signs of pain in newborns. Decreased heart rate may indicate relaxation, pinpoint pupils may suggest neurological issues, and slowed respirations may be a response to other factors.
Therefore, the most appropriate finding indicating pain in this scenario is chin quivering.
Question 4 of 5
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: FHR 152/min. At 18 weeks gestation, the fetal heart rate (FHR) typically ranges from 140-160 beats per minute, making 152/min within the normal range. This finding indicates a healthy fetal heart rate.
A: Deep tendon reflexes 4+ is not relevant to a routine assessment at 18 weeks gestation.
B: Fundal height of 14 cm is more indicative of around 12 weeks gestation, not 18 weeks.
C: Blood pressure of 142/94 mm Hg is elevated and would require further assessment and management, not expected at 18 weeks gestation.
In summary, the FHR of 152/min is the expected finding at 18 weeks gestation, making it the correct answer.
Question 5 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 action for the nurse to take first is to determine respiratory function (
Choice
A). This is because an unresponsive client may be experiencing respiratory distress, which is a life-threatening situation requiring immediate intervention. Assessing respiratory function will help the nurse identify if the client is breathing adequately or if there is a need for immediate respiratory support such as airway management or assisted ventilation.
Increasing the IV fluid rate (
Choice
B), accessing emergency medications (
Choice
C), and collecting a blood sample for coagulopathy studies (
Choice
D) are important interventions but are not the priority in this scenario. Respiratory function takes precedence as airway and breathing are essential for life and must be addressed first to ensure the client's safety and well-being.