ATI RN
ATI RN Maternal Newborn 2023 II 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: C
Rationale: The correct answer is C: Perform a vaginal examination by applying upward pressure on the presenting part. This action is crucial to assess the progress of labor, ensure proper fetal positioning, and determine if there are any complications such as cord prolapse. Administering oxygen (
B) or IV fluids (
D) may be important interventions but are not the immediate priority in this scenario. Covering the umbilical cord (
A) with a towel may increase the risk of infection.
Therefore, the key step is to perform a vaginal examination to gather essential information for appropriate decision-making.
Extract:
A nurse is caring for a client who has bladder distention following a vaginal birth.
Question 2 of 5
Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Escort the client to the bathroom. This action should be taken first to address the immediate need of the client for toileting. It promotes the client's comfort, maintains their dignity, and prevents potential complications like urinary retention. Option B (Offer the client a sitz bath) and C (Pour warm water over the client's perineum) are not priorities as they do not address the client's urgent need for toileting. Option D (Insert a urinary catheter) is an invasive procedure and should not be the first action unless indicated for a specific medical reason. Options E and F (None) are not appropriate as there is a clear immediate need that requires action.
Extract:
A nurse is providing teaching to the guardians of a preterm newborn about temperature instability.
Question 3 of 5
Which of the following statements should the nurse make?
Correct Answer: A
Rationale: The correct statement is A because preterm newborns have less muscle tone, making them more susceptible to heat loss. This is due to their underdeveloped thermoregulatory mechanisms. Shivering (
B) is not a common response in newborns and is more likely to be seen in adults. Sweating (
C) is also not a common response in newborns as their sweat glands are not fully developed. Brown fat (
D) is essential for thermoregulation in newborns and helps them stay warm, not overheat.
Therefore, A is the correct statement as it directly addresses the vulnerability of preterm newborns to heat loss due to their low muscle tone.
Extract:
A nurse is preparing to obtain a blood sample from a newborn's heel.
Question 4 of 5
In what order should the nurse perform the procedure?
Order the Items
Source Container
Correct Answer: A, B, C, D, E
Rationale: The correct order for the nurse to perform the procedure is A, B, C, D, E. First, applying a warm cloth to the newborn's heel for 5 to 10 min helps dilate the blood vessels for easier blood collection. Second, cleaning the area with an antiseptic prevents infection during the puncture. Third, puncturing the outer aspect of the newborn's heel allows for blood collection. Fourth, collecting the blood specimen is the main objective of the procedure. Finally, applying pressure to the site with a dry gauze pad helps stop bleeding and promotes healing.
Choices F and G are not provided in the question, so they are not applicable.
Extract:
A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B streptococcus B-hemolytic (GBS). The client is multigravida and multipara with no history of GBS.
Question 5 of 5
She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the following is an appropriate response by the nurse?
Correct Answer: D
Rationale: The correct answer is D because testing for Group B Streptococcus (GBS) is typically done closer to the time of delivery to determine the current status of GBS colonization, which can change throughout pregnancy. Testing earlier may not accurately reflect the GBS status at delivery.
Choice A is incorrect as the presence of symptoms is not always indicative of GBS colonization.
Choice B is incorrect as GBS status can change between pregnancies.
Choice C is incorrect because previous prenatal testing does not guarantee GBS status at delivery.