ATI RN
RN Maternal Nursing OB Newborn 2023 2024 Exam 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. The infant with neonatal abstinence syndrome is at risk for seizures due to drug withdrawal. By initiating seizure precautions, the nurse can ensure the safety of the infant by implementing measures such as padding the crib, having emergency medications readily available, and closely monitoring for any signs of seizure activity.
Choice A is incorrect because monitoring blood glucose levels every hour is not typically indicated for neonatal abstinence syndrome.
Choice B is incorrect as placing the infant on his back with legs extended does not address the risk of seizures.
Choice D is incorrect as providing a stimulating environment can exacerbate the symptoms of withdrawal.
Question 2 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, to administer the injection into the vastus lateralis muscle. In newborns, the vastus lateralis muscle is the recommended site for intramuscular injections due to its larger muscle mass and reduced risk of injury to nerves or blood vessels. This site is typically used for vaccines in infants to ensure proper absorption and minimize discomfort. Option B is incorrect as massaging the site can lead to discomfort or tissue damage. Option C is incorrect as inserting the needle at a 45° angle is not necessary for intramuscular injections in newborns. Option D is incorrect as a smaller gauge needle is usually recommended for newborns to reduce pain and tissue trauma.
Question 3 of 5
A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Administer 500 mL lactated Ringer’s IV bolus. This is the correct action because the steady trickle of vaginal bleeding coupled with ineffective fundal massage indicates postpartum hemorrhage, which can lead to hypovolemic shock. Administering a lactated Ringer's IV bolus helps to replace lost fluids and maintain hemodynamic stability.
Other choices are incorrect:
A: Replacing the surgical dressing does not address the underlying issue of postpartum hemorrhage.
B: Evaluating urinary output is important but not the priority when the client is experiencing postpartum hemorrhage.
C: Applying an ice pack to the incision site is not appropriate for managing postpartum hemorrhage.
Overall, in this scenario, administering IV fluids is the most critical intervention to address the potential life-threatening complication of postpartum hemorrhage.
Question 4 of 5
A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?
Correct Answer: D
Rationale: The correct answer is D: Jitteriness. In newborns of mothers with gestational diabetes mellitus, hypoglycemia can occur due to the abrupt cessation of the maternal glucose supply. Jitteriness is a common manifestation of hypoglycemia in newborns. This is because the brain is highly dependent on glucose for energy, and low blood sugar levels can affect neurological function, leading to symptoms like jitteriness. Abdominal distention, petechiae, and increased muscle tone are not typical manifestations of hypoglycemia in newborns with a history of maternal gestational diabetes mellitus.
Question 5 of 5
A nurse is collecting data from a client who is at 30 weeks of gestation. Which of the following findings should the nurse identify as a manifestation of pyelonephritis?
Correct Answer: B
Rationale: The correct answer is B: Flank pain. Pyelonephritis is an infection of the kidneys, which commonly presents with symptoms like flank pain. This pain is typically described as a dull ache in the lower back or sides. Other options are incorrect because:
A) Epigastric discomfort is more indicative of gastrointestinal issues;
C) A temperature of 37.7°C (99.8°F) is within normal range and not specific to pyelonephritis;
D) Abdominal cramping is more likely related to gastrointestinal or uterine issues in pregnancy.