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 to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?
Correct Answer: D
Rationale: The correct answer is D: Instruct the client to press the provided button each time fetal movement is detected. This action is crucial during a nonstress test, as pressing the button when fetal movement is felt helps to correlate fetal heart rate changes with fetal movement, providing valuable information about the baby's well-being. This allows healthcare providers to assess the baby's response to movement and determine if the fetal heart rate is within normal parameters.
Maintaining the client NPO (
Choice
A) is not necessary for a nonstress test. Placing the client in a supine position (
Choice
B) can decrease blood flow to the fetus and is contraindicated during pregnancy. Instructing the client to massage the abdomen (
Choice
C) may not be appropriate as it could potentially interfere with the test results by causing fetal movement that is not spontaneous.
Question 2 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 3 of 5
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?
Correct Answer: A
Rationale: The correct answer is A: Administer broad-spectrum antibiotics. This is crucial to prevent infection in the exposed neural tissue. Myelomeningocele increases the risk of meningitis due to the breach in the protective layers of the spinal cord. Administering antibiotics helps to prevent bacterial invasion and subsequent infection. Monitoring rectal temperature is not directly related to the myelomeningocele issue. Cleaning the site with povidone-iodine may cause further irritation to the exposed tissue. Immediate surgical closure is usually necessary to prevent infection; waiting 72 hours is not appropriate in this case.
Question 4 of 5
A nurse is collecting data from a client who is at 30 weeks of gestation. Which of the following findings should the nurse identify as a manifestation of pyelonephritis?
Correct Answer: B
Rationale: The correct answer is B: Flank pain. Pyelonephritis is a kidney infection that commonly presents with symptoms such as flank pain, fever, chills, and dysuria. Flank pain is a key manifestation due to the inflammation of the kidneys. Epigastric discomfort (choice
A) is more indicative of issues related to the stomach or upper abdomen. Temperature elevation (choice
C) is a common sign of infection but alone is not specific to pyelonephritis. Abdominal cramping (choice
D) is more likely related to gastrointestinal issues. In summary, flank pain is specific to pyelonephritis, making it the correct choice in this scenario.
Question 5 of 5
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Initiate seizure precautions. Neonatal abstinence syndrome can lead to seizures due to withdrawal from substances. Initiating seizure precautions involves ensuring a safe environment, padding the crib, and monitoring closely for any signs of seizure activity. Monitoring blood glucose every hour (
A) is unnecessary unless there are specific indications. Placing the infant on his back with legs extended (
B) is not directly related to managing neonatal abstinence syndrome. Providing a stimulating environment (
D) can exacerbate symptoms and should be avoided.