ATI RN Maternal Newborn level 3 Final Exam 2023 (All Correct

Extract:

Question 1 of 5

A nurse is caring for four antepartum clients. Which of the following clients should the nurse assess first?

A. A client who is at 7 weeks of gestation and reports urinary frequency B. A client who is at 32 weeks of gestation and reports seeing floating spots C. A client who is 38 weeks of gestation and reports leg cramps D. A client who is at 20 weeks of gestation and reports periodic numbness in her fingers

Correct Answer: B

Rationale: The correct answer is B. The nurse should assess the client who is at 32 weeks of gestation and reports seeing floating spots first. Seeing floating spots could be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. Preeclampsia can lead to severe complications for both the mother and the baby if not managed promptly.
Therefore, this client needs immediate assessment to rule out preeclampsia and ensure appropriate interventions are initiated.

Choices A, C, and D do not present with urgent signs or symptoms that require immediate attention compared to the potential severity of preeclampsia in choice B.

Question 2 of 5

A nurse is planning care for a client who is pregnant and has HIV.

A. Use a fetal scalp electrode during labor and delivery B. Bathe the newborn before initiating skin-to-skin contact C. Instruct the client to stop taking the antiretroviral medication at 32 weeks of gestation D. Administer pneumococcal immunization to the newborn within 4 hours following birth

Correct Answer: B

Rationale: The correct answer is B: Bathe the newborn before initiating skin-to-skin contact. This is because bathing the newborn before skin-to-skin contact helps reduce the risk of HIV transmission from mother to baby. HIV can be present in maternal blood and other fluids, and washing the newborn can decrease the viral load on the baby's skin. Initiating skin-to-skin contact without bathing first may increase the risk of transmission.

Choice A is incorrect because using a fetal scalp electrode during labor and delivery is unrelated to preventing HIV transmission from mother to baby.
Choice C is incorrect as stopping antiretroviral medication can be harmful to both the mother and the baby's health.
Choice D is incorrect as pneumococcal immunization is not recommended within 4 hours following birth and is not directly related to HIV transmission prevention.

Question 3 of 5

A nurse is caring for a client who has placenta previa. Which of the following findings should the nurse expect?

A. Firm rigid abdomen B. Painless vaginal bleeding C. Uterine hypertonicity D. Persistent headache

Correct Answer: B

Rationale: The correct answer is B: Painless vaginal bleeding. In placenta previa, the placenta partially or completely covers the cervix, leading to painless vaginal bleeding. This occurs due to separation of the placenta from the uterine wall. A firm rigid abdomen (
A) is more indicative of abruptio placentae. Uterine hypertonicity (
C) is seen in conditions like uterine rupture, not placenta previa. Persistent headache (
D) is not typically associated with placenta previa.

Question 4 of 5

A nurse is planning care for a newborn who is scheduled to start phototherapy using a lap.

A. Apply a thin layer lotion to the newborn's skin every 8 hours B. Dress the newborn in a thin layer of clothing during the therapy C. Ensure the newborn's eyes are closed beneath the shield D. Give the newborn 1 oz of glucose water every 4 hours

Correct Answer: C

Rationale: The correct answer is C: Ensure the newborn's eyes are closed beneath the shield. During phototherapy, the newborn's eyes need to be protected from the bright lights to prevent potential eye damage. Closing the eyes beneath the shield helps to shield them from the light exposure. This step is crucial in preventing complications and ensuring the safety and well-being of the newborn.

Other choices are incorrect because:
A: Applying lotion to the newborn's skin may interfere with the effectiveness of the phototherapy and is not necessary for the treatment.
B: Dressing the newborn in clothing may also interfere with the effectiveness of the phototherapy as the light needs direct contact with the skin.
D: Giving glucose water every 4 hours is not indicated for phototherapy and may not be appropriate for the newborn's condition.

In summary, ensuring the newborn's eyes are closed beneath the shield is the correct choice as it is essential for the safety and effectiveness of the phototherapy treatment.

Question 5 of 5

A nurse is providing discharge instructions to a client who is breastfeeding her newborn.

A. Expect 2 to 4 wet diapers every 24 hours B. Allow the baby to feed at least every 3 hours C. Offer the newborn 30 mL (1 oz.) of water between feedings D. Feed the newborn 5 to 10 minutes per breast

Correct Answer: B

Rationale: The correct answer is B: Allow the baby to feed at least every 3 hours. This is important for maintaining the baby's hydration, ensuring proper nutrition, and promoting successful breastfeeding. Feeding on demand helps establish a good milk supply and supports the baby's growth and development. Offering water (choice
C) is unnecessary and can interfere with breastfeeding. Limiting feeding time to 5-10 minutes per breast (choice
D) can prevent the baby from getting enough hindmilk, which is rich in fat and important for weight gain. Expecting 2-4 wet diapers every 24 hours (choice
A) is a general guideline but not as crucial as ensuring frequent feedings for a breastfeeding newborn.

ATI RN Maternal Newborn level 3 Final Exam 2023 (All Correct Answers). Maternal-Child Nursing -Nurselytic

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