ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 of 5
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
Correct Answer: C
Rationale: The correct answer is C: Remove all clothing from the newborn except the diaper. This action is essential during phototherapy as it maximizes the area of skin exposed to the light, promoting the breakdown of bilirubin. Adequate hydration is crucial, so option A is incorrect. Applying lotion can interfere with the effectiveness of the therapy, so option B is incorrect. Discontinuing therapy for a rash is not advisable as it may worsen the hyperbilirubinemia, making option D incorrect.
Question 2 of 5
A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?
Correct Answer: B
Rationale: The correct answer is B: Transmission can occur via the saliva and urine of the newborn. Cytomegalovirus (CMV) can be transmitted through bodily fluids such as saliva, urine, blood, and breast milk. This is important information for nurses to be aware of as they care for newborns who may be infected.
Explanation for other choices:
A: Mothers do not receive prophylactic treatment with acyclovir for CMV, as there is no specific antiviral treatment for this virus.
C: Lesions on the mother's genitalia are not a typical feature of CMV infection.
D: Airborne precautions are not required for CMV as it is primarily transmitted through bodily fluids, not through the air.
Question 3 of 5
A nurse is providing discharge teaching to a client following tubal ligation. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: D
Rationale: The correct answer is D because tubal ligation does not affect ovulation. The procedure only blocks the fallopian tubes to prevent the egg from traveling to the uterus for fertilization. Ovulation continues normally after tubal ligation.
A: Incorrect. Tubal ligation does not impact premenstrual tension.
B: Incorrect. Menstrual period length is not affected by tubal ligation.
C: Incorrect. Hormone replacements are not typically needed after tubal ligation.
In summary, the client understanding that ovulation will remain the same post-tubal ligation demonstrates comprehension of the teaching.
Question 4 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 persistent vaginal bleeding after cesarean birth could indicate hypovolemia, which requires immediate fluid resuscitation to restore blood volume. Fundal massage alone may not be sufficient if the bleeding is ongoing.
Choice A (Replace the surgical dressing) is incorrect because addressing the vaginal bleeding and hypovolemia takes priority over changing the dressing.
Choice B (Evaluate urinary output) is incorrect as it does not address the immediate need to address the potential hypovolemia from the vaginal bleeding.
Choice C (Apply an ice pack to the incision site) is incorrect as it does not address the underlying cause of the persistent vaginal bleeding and hypovolemia.
In summary, administering a fluid bolus is the most appropriate action to address the possible hypovolemia in this situation.
Question 5 of 5
A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?
Correct Answer: A
Rationale: The correct answer is A: Oligohydramnios. Electronic fetal monitoring is used to assess the well-being of the fetus during pregnancy. Oligohydramnios, which is a low level of amniotic fluid, can indicate poor fetal perfusion and compromise, necessitating closer monitoring. Hyperemesis gravidarum (
B) is severe morning sickness and does not directly affect fetal well-being. Leukorrhea (
C) is normal vaginal discharge during pregnancy and does not require fetal monitoring. Periodic tingling of the fingers (
D) is unrelated to fetal assessment.