ATI RN
ATI RN Maternal Newborn Latest Update. Questions
Extract:
Question 1 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, as the leaking cerebrospinal fluid exposes the newborn to a high risk of meningitis. Antibiotics help to prevent and treat potential bacterial infections. Monitoring rectal temperature (
B) does not address the immediate risk of infection. Cleansing the site with povidone-iodine (
C) is important but not as urgent as starting antibiotics. Surgical closure (
D) should be done promptly but not necessarily after 72 hours; infection prevention is the priority.
Question 2 of 5
A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase intake of vitamin B12. Which of the following foods should the nurse recommend?
Correct Answer: A
Rationale: The correct answer is A: Fortified soy milk. Fortified soy milk is a good source of vitamin B12, which is essential for individuals following a vegan diet as it is mainly found in animal products. Raw carrots, fresh citrus fruits, and brown rice do not contain vitamin B12. The rationale is to recommend fortified soy milk to ensure the client meets their vitamin B12 needs.
Question 3 of 5
A nurse is assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect?
Correct Answer: C
Rationale: The correct answer is C: Uterine tenderness. Postpartum endometritis is an infection of the uterine lining, causing inflammation and tenderness. This finding is characteristic of endometritis and requires immediate attention.
A: Temperature of 37.4°C is within normal range.
B: WBC count of 9,000/mm3 is within normal limits and may not indicate infection.
D: Scant lochia does not specifically indicate endometritis.
Therefore, the presence of uterine tenderness is the most significant finding in this scenario.
Question 4 of 5
A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include?
Correct Answer: D
Rationale: The correct answer is D: Allow the baby to feed at least every 3 hours. This instruction is important because frequent feeding helps to establish and maintain a good milk supply, promotes bonding, and ensures the baby receives adequate nutrition.
Choice A is incorrect as breastfeeding should not be limited to a specific time duration.
Choice B is incorrect as offering water to a newborn can interfere with breastfeeding and increase the risk of water intoxication.
Choice C is incorrect as the number of wet diapers can vary, and it is not a reliable indicator of successful breastfeeding.
Question 5 of 5
A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?
Correct Answer: A
Rationale:
Correct Answer: A - Apply a moist, warm compress to the perineum.
Rationale: Applying a moist, warm compress helps to reduce swelling and promote healing in the perineal area. This can provide comfort and pain relief for the client with a fourth-degree laceration. It also helps to increase blood flow to the area, aiding in the healing process.
Summary of other choices:
B: Providing a cool sitz bath may not be appropriate for a fourth-degree laceration as warmth is usually more soothing and beneficial.
C: Administering methylergonovine may be contraindicated as it can cause uterine contractions and increase the risk of bleeding in a client with a fourth-degree laceration.
D: Applying povidone-iodine may be too harsh for the delicate perineal area and can potentially cause irritation or delay healing.