ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 of 5
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Initiate seizure precautions. Neonatal abstinence syndrome can lead to seizures due to withdrawal from substances. Initiating seizure precautions involves ensuring a safe environment, padding the crib, and monitoring closely for any signs of seizure activity. Monitoring blood glucose every hour (
A) is unnecessary unless there are specific indications. Placing the infant on his back with legs extended (
B) is not directly related to managing neonatal abstinence syndrome. Providing a stimulating environment (
D) can exacerbate symptoms and should be avoided.
Question 2 of 5
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
Correct Answer: C
Rationale: The correct answer is C: Assist the client to empty their bladder. A uterus palpated to the right above the umbilicus in a postpartum client indicates a full bladder displacing the uterus. This can lead to uterine atony and increase the risk of postpartum hemorrhage. By assisting the client to empty their bladder, the nurse can help the uterus contract properly and prevent complications.
Other choices are incorrect:
A: Reassessing in 2 hours does not address the immediate issue of a full bladder causing uterine displacement.
B: Administering simethicone is used for gas relief and is not relevant in this situation.
D: Instructing the client to lie on their right side does not address the underlying issue of a full bladder.
In summary, emptying the bladder is crucial to prevent complications post-vaginal delivery, making it the most appropriate intervention in this scenario.
Question 3 of 5
A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Administer the injection into the vastus lateralis muscle. In newborns, the vastus lateralis muscle is the preferred site for intramuscular injections due to its size and relatively lower risk of hitting nerves or blood vessels. This muscle is located on the anterior lateral aspect of the thigh and is recommended for vaccines in infants. Administering the hepatitis B vaccine in this muscle ensures proper absorption and effectiveness of the vaccine.
Choices B, C, and D are incorrect. Massaging the site vigorously can cause discomfort and potential tissue damage. Inserting the needle at a 45° angle may result in subcutaneous rather than intramuscular injection. Using a 21-gauge needle, though commonly used, may not be the most appropriate size for newborns and can cause unnecessary pain.
Question 4 of 5
A nurse is reviewing laboratory findings for a client who is at 20 weeks of gestation. Which of the following findings should the nurse report to the provider?
Correct Answer: D
Rationale: The correct answer is D: Fasting blood glucose 180 mg/dL (74 to 106 mg/dL). During pregnancy, there is an increased risk of gestational diabetes, where blood glucose levels may become elevated. A fasting blood glucose level of 180 mg/dL is significantly higher than the normal range of 74 to 106 mg/dL, indicating hyperglycemia. High blood glucose levels can have adverse effects on both the mother and the developing fetus, such as macrosomia (large birth weight), birth complications, and potential long-term health risks.
Therefore, the nurse should report this finding to the provider promptly for further evaluation and management.
Incorrect choices:
A: Hematocrit within the range is normal during pregnancy.
B: Creatinine within the range is normal and indicates normal kidney function.
C: WBC count slightly elevated is common during pregnancy due to physiological changes.
Question 5 of 5
A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: C
Rationale: The correct answer is C: "I will continue taking my insulin if I experience nausea and vomiting." This statement indicates an understanding of the importance of insulin therapy in managing blood glucose levels, even during episodes of nausea and vomiting that may commonly occur during pregnancy. It shows that the client recognizes the need to maintain stable blood sugar levels to prevent complications for both herself and the fetus.
Choice A is incorrect because insulin needs may vary during pregnancy, but not necessarily needing to be increased in the first trimester specifically.
Choice B is incorrect because moderate exercise is generally recommended, but not when blood glucose levels are high.
Choice D is incorrect as a bedtime snack high in refined sugar can lead to blood sugar spikes.