ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 of 5
A nurse is obtaining a 2-hr postprandial blood glucose from a client. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Select the lateral side of the finger for puncture. This location is recommended for blood glucose testing as it is less painful and has fewer nerve endings compared to other areas. Puncturing the finger while still damp with antiseptic solution (choice
A) may dilute the blood sample, leading to inaccurate results. Smearing the blood onto the reagent strip (choice
B) is not recommended as it can affect the accuracy of the reading. Holding the finger above the heart prior to puncture (choice
C) may increase blood flow and lead to a higher glucose reading.
Therefore, choosing the lateral side of the finger for puncture is the best option to ensure accurate and reliable blood glucose results.
Question 2 of 5
A nurse is admitting a client to the labor and delivery unit when the client states, 'My water just broke.' Which of the following interventions is the nurse's priority?
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. This is the priority intervention because assessing the fetal heart rate (FHR) is crucial to ensuring the well-being of the fetus after the client's water has broken. Monitoring the FHR can help detect any signs of distress or complications that may arise. Performing Nitrazine testing (
A) and assessing the fluid (
B) can provide additional information, but monitoring the FHR takes precedence due to its direct impact on fetal well-being. Checking cervical dilation (
C) is important but not as urgent as monitoring the FHR in this situation.
Question 3 of 5
A nurse is caring for a newborn immediately following birth. For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?
Correct Answer: D
Rationale: The correct answer is D:
To facilitate bonding between the newborn and parent. Delaying the instillation of antibiotic ophthalmic ointment allows for uninterrupted skin-to-skin contact and bonding between the newborn and parent, which is crucial for establishing a strong emotional connection and promoting breastfeeding. This initial bonding period is a critical time for the newborn's emotional and psychological development.
Choices A, B, and C are incorrect because immediate instillation of the ointment is essential to prevent neonatal conjunctivitis, regardless of the newborn's weight, mode of delivery, or the need to identify infection manifestations.
Question 4 of 5
A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow.
Correct Answer: A,B,CD
Rationale: The correct sequence for performing Leopold maneuvers is A, B, C, and D. Firstly, palpating the fundus (
A) helps identify the fetal part and presentation. Secondly, determining the location of the fetal back (
B) provides information on the fetal lie. Next, palpating for the fetal part at the inlet (
C) helps confirm the presenting part. Lastly, identifying the attitude of the head (
D) provides important information on the fetal position for delivery. This sequence ensures a systematic approach to assessing the fetal presentation and position.
Choices E, F, and G are incorrect as they do not follow the logical order of Leopold maneuvers and may lead to inaccurate assessment.
Extract:
A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hr old.
Physical Examination:
• Fontanels soft and flat
• Head molded with caput succedaneum
• Eyes symmetric, no discharge, sclera yellow
• Mucous membranes dry
• Abdomen soft and rounded, bowel sounds present x 4 quadrants
Question 5 of 5
Which of the following findings should the nurse report to the provider? (Select all that apply.)
Correct Answer: A,B,C,G
Rationale: The correct answer is A, B, C, and G.
A: Coombs test result is important for assessing for hemolytic anemia.
B: Mucous membrane assessment can indicate hydration status and oxygenation.
C: Intake and output are crucial for assessing fluid balance.
G: Sclera color can indicate liver function or jaundice.
Other choices are incorrect because:
D: Respiratory rate is important, but not typically a priority to report unless abnormal.
E: Head assessment finding is broad and does not specify a critical finding.
F: Heart rate is important, but not as critical as the other choices.