ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 of 5
A nurse is reviewing the prescriptions for a client who is pregnant and is taking digoxin. Which of the following actions should the nurse take to best evaluate the client’s medication adherence?
Correct Answer: D
Rationale: The correct answer is D: Check the client’s serum medication level. This is the best way to evaluate medication adherence for digoxin in a pregnant client as it provides an objective measure of the drug concentration in the blood. This is important because digoxin has a narrow therapeutic range and monitoring serum levels helps ensure the drug is at an effective dose without reaching toxic levels, which can be harmful to both the mother and the fetus. Asking the client if they are taking the medication as prescribed (choice
A) relies on self-reporting, which may not always be accurate. Assessing kidney function (choice
B) and determining the apical pulse rate (choice
C) are important aspects of digoxin therapy but do not directly assess medication adherence.
Extract:
A nurse is caring for a newborn who is 70 hr old. Exhibit 1
Medical History
Newborn delivered by repeat cesarean birth at 40 weeks of gestation.
Birth weight 3,515 g (7 lb 12 oz)
Apgar scores 8 at 1 min and 9 at 5 min
Maternal history of methadone use during pregnancy.
Exhibit 2
Vital Signs
0700:
Heart rate 156/min
Respiratory rate 58/min
Temperature 37.2° C (98.9° F)
Oxygen saturation 98% on room air
1100:
Heart rate 160/min
Respiratory rate 60/min
Temperature 37.3° C (99.2° F)
Oxygen saturation 96% on room air
Exhibit 3
Physical Examination
1100:
Newborn is inconsolable with a high-pitched cry. Newborn sucks vigorously on pacifier but
breastfeeds poorly. Respirations unlabored. Lungs sound clear on auscultation. Increased muscle
tone with moderate to severe tremors when disturbed. Hyperactive Moro reflex noted. Several
loose stools today.
Exhibit 4
Diagnostic Results
Maternal urine toxicology screen positive for opiates (negative)
Newborn urine toxicology screen positive for opiates (negative)
Question 2 of 5
Which of the following findings should the nurse report to the provider? Select all that apply.
Correct Answer: C,D
Rationale: The nurse should report central nervous system (CNS) and gastrointestinal (GI) findings to the provider as they may indicate significant health issues. CNS findings can suggest neurological problems, such as changes in mental status or weakness, requiring immediate attention. GI findings, like abdominal pain or bleeding, can indicate potential digestive system issues needing prompt evaluation. Reporting respiratory findings and oxygen saturation is important too but typically not as urgent as CNS and GI issues. It is essential to prioritize CNS and GI findings for timely intervention.
Extract:
Question 3 of 5
A nurse is caring for a client who is 1 day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Assess the newborn's latch while breastfeeding. The nurse should assess the newborn's latch to ensure proper attachment to the breast, which can alleviate sore nipples. This step is crucial in addressing the root cause of the issue. Waiting 4 hours between feedings (
A) can lead to engorgement and affect milk supply. Limiting breastfeeding time to 5 minutes (
C) may not be sufficient for adequate feeding. Offering supplemental formula (
D) can interfere with establishing breastfeeding and may not address the underlying latch issue.
Question 4 of 5
A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: Monitor the client’s blood pressure every 5 min following the first dose of anesthetic solution. Monitoring blood pressure is crucial after administering epidural anesthesia to detect any potential hypotension, a common side effect. Regular monitoring allows for prompt intervention if hypotension occurs, ensuring the client's safety.
Choices A, B, and D are incorrect:
A: Placing the client in a supine position for 30 min following the first dose of anesthetic can lead to hypotension due to venous pooling in this position.
B: Administering dextrose 5% in water is not indicated for epidural anesthesia and does not address the need for blood pressure monitoring.
D: NPO status is not directly related to the need for blood pressure monitoring post-epidural administration.
Question 5 of 5
A nurse is providing discharge teaching to a client following tubal ligation. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: D
Rationale: The correct answer is D because tubal ligation does not affect ovulation. The procedure only blocks the fallopian tubes to prevent the egg from traveling to the uterus for fertilization. Ovulation continues normally after tubal ligation.
A: Incorrect. Tubal ligation does not impact premenstrual tension.
B: Incorrect. Menstrual period length is not affected by tubal ligation.
C: Incorrect. Hormone replacements are not typically needed after tubal ligation.
In summary, the client understanding that ovulation will remain the same post-tubal ligation demonstrates comprehension of the teaching.