ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 of 5
A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?
Correct Answer: C
Rationale: The correct answer is C: Headache that is unrelieved by analgesia. This is a potential sign of pregnancy-induced hypertension (pre-eclampsia), a serious complication that requires immediate medical attention to prevent harm to both the mother and the baby. Shortness of breath when climbing stairs (
A) can be a normal pregnancy symptom due to increased demand on the respiratory system. Swelling of feet and ankles (
B) is common in pregnancy but not necessarily indicative of a complication. Braxton Hicks contractions (
D) are normal, irregular contractions that do not signify labor.
Question 2 of 5
A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?
Correct Answer: D
Rationale: The correct answer is D: Third-degree perineal laceration. A suppository should not be used in a client with a third-degree perineal laceration as it can cause further irritation and delay healing. The suppository insertion could disrupt the healing tissues and increase the risk of infection.
Incorrect choices:
A: Vaginal candidiasis - This does not contraindicate the use of a suppository.
B: Abdominal distention - Unrelated to contraindicating the use of a suppository.
C: Afterpains - Not a contraindication to suppository use.
Question 3 of 5
A nurse is caring for a client who is hypotensive following the administration of epidural anesthesia. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Turn the client to a side-lying position. This action helps improve venous return to the heart and increases blood pressure in hypotensive clients. It prevents aortocaval compression, which can lead to decreased cardiac output. Turning the client to a side-lying position is a simple and effective intervention to manage hypotension in this situation.
Other choices are incorrect:
B: Applying oxygen is not the priority in this scenario as the client's hypotension is likely due to the epidural anesthesia and not respiratory distress.
C: Massaging the fundus is not indicated as the client is not postpartum or experiencing uterine atony.
D: Assisting the client to empty their bladder may be important but does not directly address the hypotension caused by epidural anesthesia.
Question 4 of 5
A nurse is obtaining a 2-hr postprandial blood glucose from a client. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Select the lateral side of the finger for puncture. This location is recommended for blood glucose testing as it is less painful and has fewer nerve endings compared to other areas. Puncturing the finger while still damp with antiseptic solution (choice
A) may dilute the blood sample, leading to inaccurate results. Smearing the blood onto the reagent strip (choice
B) is not recommended as it can affect the accuracy of the reading. Holding the finger above the heart prior to puncture (choice
C) may increase blood flow and lead to a higher glucose reading.
Therefore, choosing the lateral side of the finger for puncture is the best option to ensure accurate and reliable blood glucose results.
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.