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 requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: Monitor the client’s blood pressure every 5 min following the first dose of anesthetic solution. Monitoring blood pressure is crucial after administering epidural anesthesia to detect any potential hypotension, a common side effect. Regular monitoring allows for prompt intervention if hypotension occurs, ensuring the client's safety.
Choices A, B, and D are incorrect:
A: Placing the client in a supine position for 30 min following the first dose of anesthetic can lead to hypotension due to venous pooling in this position.
B: Administering dextrose 5% in water is not indicated for epidural anesthesia and does not address the need for blood pressure monitoring.
D: NPO status is not directly related to the need for blood pressure monitoring post-epidural administration.
Question 2 of 5
A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Verify the newborn's identification. This is the first action the nurse should take because ensuring the correct identification of the newborn is crucial for providing safe and effective care. Without proper identification, there is a risk of administering medications or treatments to the wrong newborn. Confirming the newborn's Apgar score can be important but is not as time-sensitive as verifying identification. Administering vitamin K and determining obstetrical risk factors are important tasks but should come after verifying the newborn's identification to ensure the safety of the care provided.
Extract:
A nurse is caring for a client who is at 33 weeks of gestation.
Diagnostic Results:
• Proteinuria 3+, straw-colored urine
• Platelet count 150,000/mm3 (150,000 to 400,000/mm3)
• BUN 18 mg/dL (10 to 20 mg/dL)
Question 3 of 5
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
| Findings 24 hr later | Sign of potential worsening condition | Sign of potential improvement | Unrelated to diagnosis |
|---|---|---|---|
| Hematuria | |||
| Proteinuria 2+ | |||
| Leukorrhea | |||
| Positive clonus | |||
| BUN 40 mg/dL | |||
| Platelet count 110,000/mm3 |
Correct Answer:
Rationale:
Correct Answer:
Rationale: Hematuria and Proteinuria 2+ are relevant findings indicating potential worsening conditions. Hematuria suggests possible kidney injury, while Proteinuria 2+ can indicate renal dysfunction. Leukorrhea and Positive clonus are unrelated to the diagnosis and do not provide information on the client's condition 24 hr later. BUN and platelet count are not provided in the table, so they cannot be considered for interpretation at this time.
Extract:
Question 4 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 5 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.