ATI RN
ATI RN Maternal Newborn level 3 Final Exam 2023 (All Correct Answers). Maternal-Child Nursing Questions
Extract:
Question 1 of 5
A nurse is caring for four newborns. Which of the following newborns should the nurse assess first?
Correct Answer: A
Rationale: The correct answer is A: newborn who has nasal flaring. Nasal flaring indicates respiratory distress, which is a priority concern in newborns as it can lead to hypoxia. The nurse should assess this newborn first to ensure adequate oxygenation.
B: Subconjunctival hemorrhage is common and not an urgent issue.
C: Overlapping suture lines are normal in newborns and do not require immediate attention.
D: Not passing rust-stained urine could indicate a metabolic issue but is not as urgent as respiratory distress.
Question 2 of 5
A nurse is assisting with an amniotomy on a client who is in labor. Which of the following situations should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Ensure that the fetal head is engaged. This is crucial before performing an amniotomy to prevent umbilical cord prolapse. If the fetal head is not engaged, there is a risk of cord compression. Placing the client in the left lateral position (choice
A) is not directly related to the amniotomy procedure. Giving the provider clean gloves (choice
C) is important for infection control but not specifically related to ensuring fetal head engagement. Checking the client's temperature (choice
D) is important for monitoring but not a priority before an amniotomy.
Question 3 of 5
A nurse is planning care for a client who is scheduled for a cesarian birth. Which of the following interventions should the nurse include in the plan of care?
Correct Answer: B
Rationale: The correct answer is B: Perform a surgical time out. This step is crucial before any surgical procedure, including a cesarean birth, to ensure patient safety. During the time out, the surgical team verifies the patient's identity, correct procedure, correct site, and other essential details to prevent errors. In contrast, choice A is outdated practice as current guidelines allow clear fluids up to a few hours before surgery.
Choice C is unnecessary and can increase the risk of infection.
Choice D is incorrect as metal hairpins are not recommended due to the risk of injury and interference with surgical equipment.
Question 4 of 5
A nurse is caring for a newborn who is 24 hr old. Which of the following Laboratory findings should the nurse report to the provider?
Correct Answer: D
Rationale: The correct answer is D: WBC count 32,000/mm3. A newborn with a WBC count of 32,000/mm3 indicates a potential infection, as newborns typically have a higher WBC count initially due to stress of birth. It is important to report this finding to the provider for further evaluation and possible treatment.
Choices A, B, and C are within normal range for a 24-hour-old newborn, so they do not require immediate reporting.
Choice D, Hgb 20 g/dL, is not a typical laboratory finding for a newborn and would require further investigation, but it is not as urgent as a high WBC count indicating infection.
Question 5 of 5
A nurse is caring for newborn who is 1 hr old and has a respiratory rate of 50/min, a heart rate of 130/min, and an auxiliary temperature of 36.1*C (97F). Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Apply a cap to the newborn's head. This action helps prevent heat loss through the newborn's head, which is a common area for heat loss in newborns. The respiratory rate of 50/min and heart rate of 130/min are within normal ranges for a newborn. The temperature of 36.1°C (97°F) is slightly lower than the normal range, so keeping the newborn warm is important. Giving a warm bath (choice
A) may further decrease the newborn's body temperature. Repositioning the newborn (choice
C) may not address the issue of heat loss. Obtaining an oxygen saturation level (choice
D) is not indicated based on the information provided.
Therefore, applying a cap to the newborn's head is the most appropriate action to help maintain the newborn's body temperature and prevent heat loss.