ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 of 5
A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow.
Correct Answer: A,B,CD
Rationale: The correct sequence for performing Leopold maneuvers is A, B, C, and D. Firstly, palpating the fundus (
A) helps identify the fetal part and presentation. Secondly, determining the location of the fetal back (
B) provides information on the fetal lie. Next, palpating for the fetal part at the inlet (
C) helps confirm the presenting part. Lastly, identifying the attitude of the head (
D) provides important information on the fetal position for delivery. This sequence ensures a systematic approach to assessing the fetal presentation and position.
Choices E, F, and G are incorrect as they do not follow the logical order of Leopold maneuvers and may lead to inaccurate assessment.
Question 2 of 5
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Minimal arm recoil. In a premature newborn born at 26 weeks of gestation, minimal arm recoil is expected according to the New Ballard Score. This is because premature infants have immature muscle tone, which leads to reduced arm recoil. This finding is consistent with the developmental stage of a preterm infant.
Other choices are incorrect:
B: Popliteal angle of 90° - This would not be expected in a newborn born at 26 weeks of gestation as their joints would be more flexible.
C: Creases over the entire foot sole - Premature infants may have fewer creases on their soles due to immaturity.
D: Raised areolas with 3 to 4 mm buds - Breast development is not expected in a newborn born at 26 weeks of gestation.
Question 3 of 5
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on bed rest. This is essential to prevent further clot formation and reduce the risk of embolism. Activity can dislodge the clot and lead to serious complications. Administering aspirin for pain is not appropriate as it can increase the risk of bleeding due to heparin therapy. Massaging the affected leg can also dislodge the clot. Applying cold compresses is not recommended for thrombophlebitis.
Question 4 of 5
A nurse is caring for a newborn who is 12 hr old and is experiencing jitteriness. Which of the following laboratory findings should the nurse identify as the priority?
Correct Answer: A
Rationale: The correct answer is A: Blood glucose. In a newborn experiencing jitteriness, the priority is to assess blood glucose levels as hypoglycemia can cause jitteriness and is a potentially life-threatening condition in neonates. Low blood glucose can lead to neurologic issues, seizures, and long-term developmental delays.
Total bilirubin (
B) is related to jaundice, not jitteriness. Hemoglobin (
C) and blood calcium (
D) are not directly related to jitteriness in a newborn.
Therefore, the nurse should prioritize checking the blood glucose level to address the immediate concern of jitteriness in the 12-hour-old newborn.
Question 5 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.