ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 of 5
A nurse is planning care for a client who is 1 hr postpartum and has peripartum cardiomyopathy. Which of the following actions should the nurse plan to take?
Correct Answer: B
Rationale: The correct answer is B: Assess blood pressure twice daily. Postpartum peripartum cardiomyopathy can lead to heart failure, making monitoring blood pressure crucial for early detection of worsening condition. Assessing blood pressure twice daily allows for timely intervention if hypertension or hypotension occurs. Option A, misoprostol, is used for preventing gastric ulcers, not related to peripartum cardiomyopathy. Option C, restricting oral fluid intake, is not appropriate as adequate hydration is essential postpartum. Option D, administering an IV bolus of lactated Ringer's, may not be necessary unless specifically indicated for the client's condition.
Question 2 of 5
A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?
Correct Answer: C
Rationale: The correct answer is C: Administer Rho(
D) immune globulin. This is the priority intervention because the client is Rh-negative, and an amniocentesis can lead to fetal-maternal blood incompatibility. Administration of Rho(
D) immune globulin helps prevent the mother from developing antibodies against Rh-positive fetal blood cells, reducing the risk of hemolytic disease in the fetus. Checking the client's temperature (
A) is important but not the priority immediately following an amniocentesis. Observing for uterine contractions (
B) is not the priority unless there are signs of preterm labor. Monitoring the FHR (
D) is essential but not the priority immediately post-amniocentesis.
Question 3 of 5
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
Correct Answer: A
Rationale: The correct answer is A: Substernal retractions. Substernal retractions in a newborn indicate respiratory distress, which is a serious concern that requires immediate attention from the provider. The other choices are normal findings in a newborn. Acrocyanosis is common and resolves on its own. Overlapping suture lines are expected due to the molding of the infant's head during birth. A head circumference of 33 cm (13 in) falls within the normal range for a newborn. Reporting substernal retractions promptly ensures timely intervention to address potential respiratory issues.
Question 4 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 5 of 5
A nurse is caring for a client who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following actions should the nurse take next?
Correct Answer: B
Rationale: The correct answer is B: Cover the umbilical cord with a sterile saline-saturated towel. This action is crucial to prevent umbilical cord compression, maintain blood flow to the fetus, and reduce the risk of hypoxia. By covering the umbilical cord with a sterile saline-saturated towel, the nurse can protect the cord from further compression and potential infection. Performing a vaginal examination (choice
A) could worsen the situation by causing more cord compression. Administering oxygen (choice
C) is important but covering the cord takes priority. Initiating IV fluids (choice
D) is not the immediate priority in this emergency situation.