ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 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.
Question 2 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: The correct answer is A: Apply a moist, warm compress to the perineum. This action helps reduce swelling, promote circulation, and provide comfort to the client with a fourth-degree laceration. Moist heat can also aid in pain relief and improve healing by increasing blood flow to the area.
Choice B is incorrect as a cool sitz bath may not be appropriate for a client with a fourth-degree laceration, as it can potentially cause discomfort and may not promote healing.
Choice C, administering methylergonovine, is not indicated for a perineal laceration but rather for postpartum hemorrhage.
Choice D, applying povidone-iodine, can be too harsh for the healing perineal tissue and may cause irritation.
Question 3 of 5
A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position. Which of the following questions should the nurse ask to evaluate the effectiveness of this intervention?
Correct Answer: D
Rationale: The correct answer is D: "Has your back labor improved?" This question is relevant because the occipitoposterior position can cause intense back pain during labor. By asking if the back pain has improved, the nurse can assess the effectiveness of the hands-and-knees position in helping to alleviate this specific discomfort.
Choice A: "Does that lessen your suprapubic pain?" is incorrect because the hands-and-knees position is not specifically targeted at suprapubic pain.
Choice B: "Are you feeling relief from your pelvic pressure?" is incorrect because the hands-and-knees position is more effective for back pain relief rather than pelvic pressure.
Choice C: "Do your contractions feel further apart?" is incorrect because the position change may not directly affect the frequency of contractions.
In summary, the correct question (
D) focuses on the specific issue of back labor associated with occipitoposterior position, making it the most relevant evaluation of the intervention.
Question 4 of 5
A nurse is caring for a client who is in labor and reports increasing rectal pressure. They are experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that their cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?
Correct Answer: B
Rationale: The correct answer is B: Active phase of labor. At 9 cm dilation, the client is transitioning from the latent phase to the active phase. In the active phase, the cervix typically dilates from 6 to 10 cm. The client's contractions are close together and long-lasting, indicating active labor. Rectal pressure is common during the active phase as the baby descends further. The passive descent (
A) phase occurs later in labor when the cervix is fully dilated, and the client is ready to push. Early phase (
C) is characterized by slow cervical dilation from 0 to 6 cm. Descent (
D) phase is not a recognized phase of labor.
Question 5 of 5
A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?
Correct Answer: D
Rationale: The correct answer is D: Jitteriness. Newborns of mothers with gestational diabetes are at risk for hypoglycemia due to their own insulin production being higher to compensate for the mother's high glucose levels. Jitteriness is a common sign of hypoglycemia in newborns due to the brain's dependence on glucose for energy. Abdominal distention, petechiae, and increased muscle tone are not typical manifestations of hypoglycemia in newborns. Abdominal distention may indicate other issues such as bowel obstruction, petechiae can be a sign of bleeding disorders, and increased muscle tone is not specific to hypoglycemia.