ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake 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 essential to prevent further clot formation and reduce the risk of embolism. Activity can dislodge the clot and lead to serious complications. Administering aspirin for pain is not appropriate as it can increase the risk of bleeding due to heparin therapy. Massaging the affected leg can also dislodge the clot. Applying cold compresses is not recommended for thrombophlebitis.
Question 2 of 5
A nurse is assessing a client who is postpartum following a cesarean birth. The client states, 'I feel like I have to urinate but I can’t go.' Which of the following actions should the nurse take?
Correct Answer: A
Rationale:
Rationale:
Choice A is correct because assisting the client to ambulate to the bathroom can help relieve pressure on the bladder and facilitate urination. Walking can also help stimulate bladder emptying. Inserting a urinary catheter (
Choice
B) is invasive and should be avoided unless necessary. Performing a bladder scan (
Choice
C) may be considered if the client continues to have difficulty urinating after ambulating. Administering a diuretic (
Choice
D) is not indicated as it may exacerbate the issue by increasing urine production without addressing the underlying cause.
Question 3 of 5
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)
Correct Answer: A,C
Rationale:
Correct Answer: A, C
Rationale:
A: Flaccid uterus indicates uterine atony, a common postpartum complication causing excessive bleeding. Oxytocin helps contract the uterus, reducing bleeding.
C: Excess vaginal bleeding is a sign of postpartum hemorrhage. Oxytocin helps by stimulating uterine contractions to control bleeding.
B: Cervical laceration doesn't directly relate to oxytocin administration. It requires repair and not oxytocin.
D: Increased afterbirth cramping is a normal response after delivery, not a direct indication for oxytocin.
Question 4 of 5
A nurse is obtaining a 2-hr postprandial blood glucose from a client. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Select the lateral side of the finger for puncture. This location is recommended for blood glucose testing as it is less painful and has fewer nerve endings compared to other areas. Puncturing the finger while still damp with antiseptic solution (choice
A) may dilute the blood sample, leading to inaccurate results. Smearing the blood onto the reagent strip (choice
B) is not recommended as it can affect the accuracy of the reading. Holding the finger above the heart prior to puncture (choice
C) may increase blood flow and lead to a higher glucose reading.
Therefore, choosing the lateral side of the finger for puncture is the best option to ensure accurate and reliable blood glucose results.
Question 5 of 5
A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Excessive crying. Neonatal abstinence syndrome is characterized by withdrawal symptoms in newborns exposed to drugs in utero. Excessive crying is a common manifestation due to irritability and discomfort. Diminished deep tendon reflexes (
A) are not typically associated. Decreased muscle tone (
C) may be present but is not a defining feature. Absent Moro reflex (
D) is not a typical finding in neonatal abstinence syndrome.