ATI RN
ATI RN Maternal Newborn level 3 Final Exam 2023 (All Correct Answers). Maternal-Child Nursing Questions
Extract:
Question 1 of 5
A nurse on a labor and delivery unit is receiving infection control standards with a newly licensed nurse. The nurse should instruct the newly licensed nurse to don gloves for which of the following procedures?
Correct Answer: D
Rationale:
Rationale: Donning gloves for performing umbilical cord care is crucial to prevent infection transmission. The umbilical cord stump is a potential entry point for pathogens, so gloves provide a barrier. Assisting with breastfeeding (
A) does not require gloves unless there are open wounds on the mother's breast. Performing a newborn's bath (
B) does not involve contact with bodily fluids that necessitate glove use. Administering a vaccine (
C) requires clean technique, not necessarily gloves. Summary:
Choices A, B, and C do not involve direct exposure to bodily fluids or potential infection sources, so gloves are not necessary.
Choice D involves direct contact with a potential infection source, making gloves essential.
Question 2 of 5
A nurse is caring for a client who reports spontaneous rupture. The nurse observed fetal bradycardia in the FHR tracing and notices the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following should the nurse take next?
Correct Answer: D
Rationale: The correct answer is D: Cover the umbilical cord with sterile saline saturated towel. This action is essential to prevent compression and protect the exposed cord from infection. By covering the umbilical cord with a sterile saline-saturated towel, the nurse can maintain the cord's moisture and integrity, reducing the risk of cord compression and infection. This step is crucial in managing a prolapsed umbilical cord until emergency interventions can be performed.
Summary:
A: Initiating IV fluids is not the priority in this situation as the immediate concern is to protect the umbilical cord.
B: Performing a vaginal examination by applying upward pressure can further compress the cord and worsen the fetal distress.
C: Administering oxygen is important but is not the immediate priority compared to protecting the umbilical cord.
E, F, G: Not applicable.
Question 3 of 5
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan?
Correct Answer: C
Rationale: Rationale for Correct Answer C (Ensure the newborn eyes are closed beneath the shield):
- Phototherapy exposes the newborn's skin to light to treat jaundice.
- It's crucial to protect the newborn's eyes from the bright light to prevent damage.
- Closing the eyes beneath the shield helps shield the sensitive eyes from potential harm.
Summary of Incorrect
Choices:
- A: Applying lotion may increase the risk of skin irritation during phototherapy.
- B: Giving glucose water is unrelated to phototherapy and may not be indicated.
- D: Dressing the newborn may hinder the effectiveness of phototherapy as more skin should be exposed to light.
Question 4 of 5
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lap.
Correct Answer: C
Rationale: The correct answer is C because during phototherapy, the newborn's eyes need to be protected from the light to prevent damage. Placing a shield over the eyes ensures that the light does not harm the delicate eyes. Applying lotion is unnecessary and could interfere with the effectiveness of the therapy. Dressing the newborn in clothing may block the light from reaching the skin, reducing the therapy's effectiveness. Giving glucose water is unrelated to phototherapy and could be harmful to the newborn.
Question 5 of 5
A nurse is caring for a newborn who is 6 hr old and has a bedside glucometer reading of 65 mg/ dL. The newborn’s mother has type 2 diabetes mellitus. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Feed the newborn immediately. Newborns of diabetic mothers are at risk for hypoglycemia due to fetal hyperinsulinemia. A bedside glucometer reading of 65 mg/dL in a 6-hour-old newborn indicates hypoglycemia. Immediate feeding with breast milk or formula is the initial treatment for neonatal hypoglycemia as it helps increase blood glucose levels. This helps prevent further complications such as seizures and brain damage. Options A, C, and D are incorrect:
A) Obtaining a blood sample for a serum glucose level delays immediate intervention,
C) Administering dextrose IV should be reserved for severe hypoglycemia, and
D) Reassessing blood glucose level before feeding delays necessary treatment.