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 in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
Correct Answer: B
Rationale: The correct answer is B: Temperature. During an amniotomy, there is a risk of infection due to the introduction of bacteria into the amniotic cavity. Monitoring the client's temperature is crucial to identify any signs of infection promptly. Elevated temperature can indicate infection, which can lead to serious complications for both the client and the baby. O2 saturation, blood pressure, and urinary output are important assessments but are not the priority in this situation. Monitoring temperature will help the nurse detect early signs of infection and initiate appropriate interventions.
Question 2 of 5
A nurse is assessing a newborn who was born postterm. Which of the following findings should the nurse expect?
Correct Answer: C
Rationale: The correct answer is C: Nails extending over tips of fingers. Postterm newborns have longer nails due to prolonged intrauterine exposure. This is because their nails continue to grow during the extended time in the womb. Large deposits of subcutaneous fat (
A) are more common in term and postterm newborns. A thin covering of fine hair on shoulders and back (
B) is known as lanugo and is typically seen in preterm newborns. Pale, translucent skin (
D) is more common in preterm newborns due to decreased fat deposits.
Therefore, the most expected finding in a postterm newborn is nails extending over the tips of fingers.
Question 3 of 5
A nurse is caring for a client who is at 10 weeks of gestation. Which of the following findings should the nurse report to the provider?
Correct Answer: A
Rationale: The correct answer is A. Frequent vomiting with weight loss of 3 lb in 1 week is concerning as it may indicate hyperemesis gravidarum, a severe form of morning sickness that can lead to dehydration and electrolyte imbalance, posing risks to both the mother and fetus. The nurse should report this finding to the provider for further evaluation and intervention.
B: Reports of mood swings are common during pregnancy due to hormonal changes and are not typically a cause for concern at this gestational age.
C: Nosebleeds occurring approximately 3 times per week are common in pregnancy due to increased blood volume and nasal congestion and do not typically require immediate provider notification.
D: Increased vaginal discharge is a normal finding in pregnancy due to hormonal changes and increased blood flow to the pelvic area and does not typically necessitate immediate provider notification.
Question 4 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.
Extract:
A nurse is assessing a postpartum client during a follow-up visit.
Exhibit 3 - Vital Signs
Time Vital Signs
0930 Temperature 37°C (98.6°F)
Pulse rate 78/min
Respiratory rate 12/min
Blood pressure 124/80 mm Hg
Pulse oximetry 100%
Question 5 of 5
The nurse is teaching the client about postpartum depression. The nurse should encourage the client to----------------- and ----------------- to help prevent postpartum depression.
Correct Answer: B,E
Rationale: The correct answers are B and E. Maintaining a strong support system is crucial for emotional well-being, as it provides the client with reassurance, understanding, and help in times of need. This can help prevent feelings of isolation and loneliness, common in postpartum depression. Additionally, exercising for at least 30 minutes per day can release endorphins, improve mood, and reduce stress, all of which can contribute to preventing postpartum depression.
Choices A, C, and D are important for overall health but do not specifically address the emotional and mental aspects that can lead to postpartum depression.