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 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include?
Correct Answer: D
Rationale:
Rationale: Option D is correct because pressing the handheld button when feeling the baby move during the nonstress test helps to record fetal movements and heart rate changes. This action ensures accurate monitoring of the baby's well-being. Option A is incorrect because the duration of the test can vary and is not necessarily limited to 10-15 minutes. Option B is incorrect as pregnant clients should not lie in a supine position for extended periods due to the risk of supine hypotensive syndrome. Option C is incorrect as fasting is not necessary for a nonstress test.
Extract:
A nurse is caring for a newborn.
Exhibit 1
Medical History
1600:
Apgar score 9 at 1 min and 9 at 5 min
Birth weight 4,706 g (10 lb 6 oz)
Gestational age 40 weeks
Difficult vaginal birth with shoulder dystocia. Exhibit 2
Nurses' Notes
1700:
Newborn is active and moves all extremities except for right arm. No spontaneous movement of
the right arm noted. Right arm remains at side during Moro reflex. Exhibit 3
Physical Examination
1830:
Absent Moro reflex noted in right arm.
Right shoulder and arm are internally rotated and adducted. Elbow extended. Forearm pronated
with wrist and fingers flexed. Diagnosis: Brachial plexus injury resulting in Erb-Duchenne (Erb's
palsy) paralysis.
Question 2 of 5
Which of the following actions should the nurse plan to implement? For each potential nursing action, click to specify if the intervention is indicated or contraindicated for the newborn.
| Potential Nursing Action | Indicated | Contraindicated |
|---|---|---|
| Educate the parents to begin range of motion exercises on the affected arm after 1 week. | ||
| Assess for grasp reflex in the affected extremity. | ||
| Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt. | ||
| Instruct parents to limit physical handling for 2 weeks. |
Correct Answer:
Rationale: [
,
(0, 1, 1),
(0, 0, 1),
(0, 1, 0)
]
Correct Answer: (
B) Assess for grasp reflex in the affected extremity.
Rationale: Assessing for grasp reflex is indicated to evaluate neurological function and response in the affected extremity. Range of motion exercises (
A) are contraindicated as they may exacerbate the condition. Immobilizing the arm (
C) can hinder normal movement and development. Limiting physical handling (
D) may impede bonding and care interactions.
Extract:
Question 3 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. In a nonstress test, the client is instructed to press a button each time fetal movement is detected. This action helps to correlate fetal movement with fetal heart rate patterns, providing valuable information on fetal well-being. Maintaining NPO status (
A) is not necessary for this test. Placing the client in a supine position (
B) can compress the vena cava and decrease blood flow to the fetus. Instructing the client to massage the abdomen (
C) may artificially stimulate fetal movement, affecting the test results.
Extract:
A nurse is caring for a client who is experiencing a postpartum hemorrhage and has a new prescription for misoprostol.
Exhibit 2: Medical History
Preeclampsia
Cesarean birth of viable twin male newborns
Question 4 of 5
The nurse is assessing the client 30 min later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
| Findings 30 min later | Unrelated to diagnosis | Indication Of potential improvement | Indication of Potential worsening condition |
|---|---|---|---|
| Fundus at level of umbilicus | |||
| Cloudy urine | |||
| Blood pressure 80/50 mm Hg | |||
| Moderate lochia rubra | |||
| Thready pulse | |||
| Fundus firm to palpation |
Correct Answer:
Rationale:
Correct Answer:
Rationale:
- Fundus at the level of the umbilicus is an indication of potential improvement as it indicates proper involution of the uterus.
- Cloudy urine is unrelated to the diagnosis and may indicate other issues like urinary tract infection.
- Blood pressure of 80/50 mm Hg is an indication of potential worsening condition as it is hypotensive.
- Moderate lochia rubra is also an indication of potential worsening condition as it may indicate excessive bleeding.
- Thready pulse is unrelated to the diagnosis.
- Fundus firm to palpation is an indication of potential improvement as it indicates proper uterine contraction and involution.
Extract:
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.