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:
Correct Answer: C - Remove all clothing from the newborn except the diaper.
Rationale: Phototherapy involves exposing the newborn's skin to light to breakdown excess bilirubin.
To maximize the effectiveness of phototherapy, the newborn should have as much skin exposed to the light as possible. Removing all clothing except the diaper ensures that the most surface area is exposed to the light, improving bilirubin breakdown.
Summary of other choices:
A: Feeding water is not directly related to phototherapy for hyperbilirubinemia.
B: Applying lotion does not aid in the effectiveness of phototherapy.
D: Discontinuing therapy due to a rash may compromise the treatment of hyperbilirubinemia.
Question 2 of 5
A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Apply a moist, warm compress to the perineum. This action helps reduce swelling, promote circulation, and provide comfort to the client with a fourth-degree laceration. Moist heat can also aid in pain relief and improve healing by increasing blood flow to the area.
Choice B is incorrect as a cool sitz bath may not be appropriate for a client with a fourth-degree laceration, as it can potentially cause discomfort and may not promote healing.
Choice C, administering methylergonovine, is not indicated for a perineal laceration but rather for postpartum hemorrhage.
Choice D, applying povidone-iodine, can be too harsh for the healing perineal tissue and may cause irritation.
Question 3 of 5
A nurse is preparing to administer an IM injection to a newborn. Which of the following sites should the nurse select?
Correct Answer: A
Rationale: The correct site for an IM injection in a newborn is the vastus lateralis muscle. This site is recommended for infants due to the larger muscle mass, reduced risk of injury to nerves and blood vessels, and better absorption of the medication. The vastus lateralis is located on the lateral aspect of the thigh and is easily accessible for injections. In contrast, the dorsogluteal site is not recommended in infants due to the proximity of the sciatic nerve and the risk of injury. The deltoid muscle is typically used for older children and adults, not newborns. The rectus femoris muscle is not a commonly used site for IM injections in newborns. Selecting the vastus lateralis ensures safe and effective administration of the medication.
Question 4 of 5
A nurse is assessing a newborn following a forceps-assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of this birth method?
Correct Answer: D
Rationale: The correct answer is D: Facial palsy. Forceps-assisted birth can lead to pressure on the facial nerve, resulting in facial nerve injury and facial palsy in the newborn. This can manifest as weakness or paralysis of facial muscles. Polycythemia (
A) is not typically associated with forceps-assisted birth. Hypoglycemia (
B) may occur due to various reasons but is not directly related to the birth method. Bronchopulmonary dysplasia (
C) is a lung condition often seen in premature infants on long-term ventilation. In summary, facial palsy is a potential complication of forceps-assisted birth due to nerve compression, while the other options are less likely to be directly linked to this birth method.
Question 5 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.