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 newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan?
Correct Answer: C
Rationale: Rationale for Correct Answer C (Ensure the newborn eyes are closed beneath the shield):
- Phototherapy exposes the newborn's skin to light to treat jaundice.
- It's crucial to protect the newborn's eyes from the bright light to prevent damage.
- Closing the eyes beneath the shield helps shield the sensitive eyes from potential harm.
Summary of Incorrect
Choices:
- A: Applying lotion may increase the risk of skin irritation during phototherapy.
- B: Giving glucose water is unrelated to phototherapy and may not be indicated.
- D: Dressing the newborn may hinder the effectiveness of phototherapy as more skin should be exposed to light.
Question 2 of 5
A nurse is caring for a client who is receiving oxytocin to induce labor. The nurse should discontinue the oxytocin if which of the following occurs?
Correct Answer: A
Rationale: The correct answer is A: Contractions last 60 seconds. Prolonged contractions can lead to uterine tachysystole, which can reduce placental perfusion and oxygenation to the fetus. This can result in fetal distress and compromise. Non-repetitive early decelerations (
B) are common and not a reason to discontinue oxytocin. 6 contractions in 10 minutes (
C) is within the normal range. Moderate variability of the fetal heart rate (
D) is a sign of good oxygenation and fetal well-being, indicating that oxytocin can continue.
Question 3 of 5
A nurse is preparing to perform a fundal massage for a postpartum client with hearing seeing uterine atony. In which order should the nurse plan to perform the following actions? (molded steps into the box on the right. Placing them in order of performance use all steps)
Correct Answer: A,B,C.D
Rationale: Action to Take: A, B; Potential Condition: Uterine atony; Parameter to Monitor: Perineum for clots, Amount of bleeding.
Rationale: A helps position the client for the massage. B establishes proper hand placement. C guides the massage technique for uterine stimulation. D is crucial to monitor post-massage for complications.
Incorrect
Choices: The remaining choices do not contribute directly to fundal massage or monitoring postpartum hemorrhage.
Question 4 of 5
A nurse is caring for a client who reports spontaneous rupture. The nurse observed fetal bradycardia in the FHR tracing and notices the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following should the nurse take next?
Correct Answer: D
Rationale: The correct answer is D: Cover the umbilical cord with sterile saline saturated towel. This action is essential to prevent compression and protect the exposed cord from infection. By covering the umbilical cord with a sterile saline-saturated towel, the nurse can maintain the cord's moisture and integrity, reducing the risk of cord compression and infection. This step is crucial in managing a prolapsed umbilical cord until emergency interventions can be performed.
Summary:
A: Initiating IV fluids is not the priority in this situation as the immediate concern is to protect the umbilical cord.
B: Performing a vaginal examination by applying upward pressure can further compress the cord and worsen the fetal distress.
C: Administering oxygen is important but is not the immediate priority compared to protecting the umbilical cord.
E, F, G: Not applicable.
Question 5 of 5
A nurse is caring for four newborns. Which of the following newborns should the nurse assess first?
Correct Answer: A
Rationale: The correct answer is A because nasal flaring indicates respiratory distress, which is a critical condition requiring immediate assessment and intervention to ensure adequate oxygenation. Nasal flaring is a sign of increased work of breathing and potential airway obstruction. Subconjunctival hemorrhage (
B) is a common and benign finding in newborns, not requiring urgent attention. Overlapping suture lines (
C) are typically seen in newborns and may resolve on their own without intervention. Rust-stained urine (
D) may indicate the presence of uric acid crystals, which is common in newborns and not typically a cause for immediate concern.
Therefore, assessing the newborn with nasal flaring first is crucial to ensure their respiratory status is stable.