ATI RN
ATI RN Maternal Newborn 2023 Questions
Extract:
A nurse is caring for a client who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding.
Question 1 of 5
After calling for assistance and notifying the provider, which of the following actions should the nurse take next?
Correct Answer: D
Rationale: The correct answer is D: Perform a vaginal examination by applying upward pressure on the presenting part. This action is crucial to assess the progress of labor and determine if there is a risk of cord prolapse, a serious obstetric emergency. By applying upward pressure, the nurse can alleviate pressure on the cord and prevent potential complications. Administering oxygen (
A) may be necessary but is not the immediate priority. Covering the umbilical cord (
B) does not address the potential emergency. Initiating IV fluids (
C) is important, but assessing the cord position takes precedence.
Extract:
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid.
Question 2 of 5
Which of the following actions should the nurse include in the plan of care?
Correct Answer: A
Rationale: The correct answer is A: Administer broad-spectrum antibiotics. This is essential in the plan of care to treat a suspected infection. Antibiotics can target a wide range of bacteria, covering potential pathogens until specific cultures can identify the causative organism. Cleansing the site with povidone-iodine (
B) is important for local hygiene but does not address systemic infection. Monitoring rectal temperature (
C) is a good assessment measure but does not actively treat infection. Preparing for surgical closure after 72 hr (
D) may be necessary but does not address the immediate need to manage infection.
Extract:
A nurse is assessing a newborn who was born 2 hr ago and was admitted to the neonatal intensive care unit with chest wall retractions and blue discoloration of the hands and feet.
Question 3 of 5
Which of the following findings indicates a decline in the newborn's status?
Correct Answer: C
Rationale:
Correct
Answer: C - Oxygen saturation of 89%
Rationale: A newborn's oxygen saturation should ideally be above 95%. A level of 89% indicates hypoxemia, which can lead to serious complications like brain damage. Monitoring oxygen saturation is crucial in assessing the newborn's respiratory status.
Summary of other choices:
A: Apneic episode less than 15 seconds - Can be a normal finding in newborns and may not necessarily indicate a decline in status.
B: Fine crackles - Can be a common finding in newborns and may not directly indicate a decline in status.
D: Nasal flaring - Can be a sign of respiratory distress but may not always indicate a decline in status.
Extract:
A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique.
Question 4 of 5
Which of the following information should the nurse include?
Correct Answer: B
Rationale: The correct answer is B: Notify the provider if the end of your baby's penis appears dark red. This is important as it could indicate a complication like infection or inadequate blood flow. A: Yellow exudate is not a normal finding and should be reported immediately. C: The Plastibell is typically removed after a few days, not 4 hours. D: A snug diaper can cause pressure on the circumcision site, leading to complications.
Extract:
A nurse is administering a hepatitis B vaccine to a newborn.
Question 5 of 5
Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Administer the injection into the vastus lateralis muscle. This is the correct action because the vastus lateralis muscle is a recommended site for intramuscular injections in adults due to its large, well-developed muscle mass and lower risk of hitting nerves or blood vessels. Using a 21-gauge needle (choice
A) is not specified for this particular injection and may not be appropriate for all medications. Inserting the needle at a 45° angle (choice
B) is not necessary for the vastus lateralis muscle and may not ensure proper depth of injection. Vigorously massaging the site (choice
D) can cause tissue damage and is not recommended post-injection.