ATI RN
ATI RN Maternal Newborn level 3 Final Exam 2023 (All Correct Answers). Maternal-Child Nursing Questions
Extract:
Question 1 of 5
A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care?
Correct Answer: B
Rationale: The correct answer is B: Avoid using lotion or ointment on the newborn skin. Phototherapy is used to treat jaundice in newborns by breaking down bilirubin in the skin. Using lotions or ointments can interfere with the effectiveness of phototherapy as they can block the light from reaching the skin. Dressing the newborn in lightweight clothing can help expose more skin to the light. Keeping the newborn supine throughout treatment is not necessary for phototherapy. Measuring the newborn's temperature every 8 hours is important but not directly related to phototherapy.
Question 2 of 5
A nurse is assessing a client who is in preterm labor and has a new prescription for terbutaline 0.25 mg subcutaneous. For which of the following findings should the nurse withhold the medication and report to the provider?
Correct Answer: B
Rationale: The correct answer is B: Blood pressure 88/58 mmHg. Terbutaline is a tocolytic medication used to stop preterm labor by relaxing the uterine muscles. Hypotension is a potential side effect of terbutaline due to its beta-adrenergic agonist properties. A blood pressure of 88/58 mmHg indicates hypotension, which can be exacerbated by terbutaline. The nurse should withhold the medication and promptly report this finding to the provider to prevent further complications such as decreased perfusion to vital organs.
Incorrect choices:
A: Fasting blood glucose 75 mg/dL - Normal blood glucose level, not contraindicated for terbutaline administration.
C: Urinary output 40 mL/hr - Normal urinary output, not contraindicated for terbutaline administration.
D: FHR 120/min - Normal fetal heart rate, not contraindicated for terbutaline
Question 3 of 5
A nurse is caring for a newborn who is 6 hr old and has a bedside glucometer reading of 65 mg/ dL. The newborn’s mother has type 2 diabetes mellitus. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Feed the newborn immediately. Newborns of diabetic mothers are at risk for hypoglycemia due to fetal hyperinsulinemia. A bedside glucometer reading of 65 mg/dL in a 6-hour-old newborn indicates hypoglycemia. Immediate feeding with breast milk or formula is the initial treatment for neonatal hypoglycemia as it helps increase blood glucose levels. This helps prevent further complications such as seizures and brain damage. Options A, C, and D are incorrect:
A) Obtaining a blood sample for a serum glucose level delays immediate intervention,
C) Administering dextrose IV should be reserved for severe hypoglycemia, and
D) Reassessing blood glucose level before feeding delays necessary treatment.
Question 4 of 5
A nurse on postpartum unit caring for four clients. Which of the following clients should receive Rh, (D) Immune globulin to prevent Rh- is immunization?
Correct Answer: A
Rationale: The correct answer is A. When an Rh-negative mother has an Rh-positive infant, there is a risk of sensitization if fetal blood mixes with maternal blood during delivery. Rh(
D) Immune globulin is given to prevent this sensitization by destroying any fetal Rh-positive red blood cells that may have entered the maternal circulation. This prevents the mother from forming antibodies against Rh-positive blood in subsequent pregnancies.
Choices B, C, and D are incorrect because they do not present a risk of sensitization. In choice B, an Rh-positive mother with an Rh-negative infant does not require Rh(
D) Immune globulin. In choice C, an Rh-positive mother with an Rh-positive infant does not require Rh(
D) Immune globulin. In choice D, an Rh-negative mother with an Rh-negative infant does not require Rh(
D) Immune globulin as there is no risk of sensitization in this scenario.
Question 5 of 5
A nurse is caring for a client who is at 30 weeks of gestation. The nurse should plan to immunize the client with which of the following vaccinations? Select all that apply.
Correct Answer: C,D
Rationale: The correct answers are C (Diphtheria - acellular pertussis) and D (Inactivated influenza) for a client at 30 weeks of gestation. These vaccinations are safe and recommended during pregnancy to protect both the mother and baby. Diphtheria and pertussis protection is important to prevent transmission to the newborn. Influenza vaccine reduces the risk of severe complications for the mother and baby. Varicella (
A) and Human papillomavirus (
B) vaccines are contraindicated during pregnancy due to potential risks to the fetus.