ATI RN
RN ATI Maternal Newborn 2023 with NGN Questions
Extract:
Question 1 of 5
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on bed rest. This is important to prevent dislodgement of the clot and further complications associated with thrombophlebitis. Moving the client around can increase the risk of clot migration. Administering aspirin for pain (choice
A) is not appropriate as it can increase the risk of bleeding with heparin therapy. Massaging the affected leg every 12 hours (choice
C) can also dislodge the clot and is contraindicated. Applying cold compresses to the affected calf (choice
D) can also increase the risk of clot dislodgement.
Therefore, the best action is to maintain the client on bed rest to minimize the risk of complications.
Question 2 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. Incorrect identification can lead to errors in medication administration, treatment, and monitoring. Confirming the newborn's Apgar score (
A) is important for assessing the newborn's initial condition but is not the priority in this situation. Administering vitamin K (
C) is essential for newborns but can be done after verifying identification. Determining obstetrical risk factors (
D) is important for understanding the newborn's medical history but is not the immediate priority.
Question 3 of 5
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?
Correct Answer: C
Rationale: The correct answer is C: Urine output of 280 mL within 8 hr. In hyperemesis gravidarum, a low urine output may indicate dehydration despite IV fluid replacement. This finding is critical as it suggests inadequate renal perfusion. A reduced urine output can lead to electrolyte imbalances and compromised fetal well-being. Reporting this to the provider is essential for prompt intervention.
Choices A, B, and D are within normal limits for a client with hyperemesis gravidarum. A blood pressure of 105/64 mm Hg and heart rate of 98/min can be expected due to dehydration. Urine negative for ketones is a positive finding, indicating improved hydration and reduced risk of metabolic complications.
Question 4 of 5
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Report the client's condition to the local health department. This action is crucial to ensure that proper public health measures can be taken to prevent the spread of HIV to others. Reporting the client's condition will also enable the health department to provide necessary support and resources for the client and her baby. Administering penicillin G (choice
A) is not indicated for an HIV-positive client at 22 weeks of gestation. Annual pelvic exams (choice
B) are important but not the priority in this case. Waiting to start HIV medication until after delivery (choice
C) is not recommended as early treatment is essential.
Question 5 of 5
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
Correct Answer: C
Rationale: The correct answer is C: Remove all clothing from the newborn except the diaper. This is important during phototherapy as it maximizes the skin surface exposed to the light, aiding in bilirubin breakdown.
Choice A is incorrect as water feeds are unnecessary and may interfere with breastfeeding.
Choice B is incorrect as lotions can interfere with the effectiveness of phototherapy.
Choice D is incorrect as a rash is a common side effect of phototherapy and does not warrant discontinuation of the therapy.