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 is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position.
Question 2 of 5
Which of the following questions should the nurse ask to evaluate the effectiveness of this intervention?
Correct Answer: C
Rationale:
Rationale: The nurse should ask about the improvement in back labor as it directly evaluates the effectiveness of the intervention related to back pain relief. Contractions, pelvic pressure, and suprapubic pain are not directly related to back labor.
Therefore, asking about back labor improvement is the most relevant way to assess the intervention's success.
Extract:
A nurse is planning care for a client who is 1 hr postpartum and has peripartum cardiomyopathy.
Question 3 of 5
Which of the following actions should the nurse plan to take?
Correct Answer: A
Rationale: The correct answer is A: Restrict daily oral fluid intake. This is the appropriate action for a patient with fluid overload, as it helps manage fluid balance. Restricting fluid intake can prevent further fluid accumulation and complications. Administering an IV bolus of lactated Ringer's (
B) would worsen fluid overload. Assessing blood pressure twice daily (
C) is important but not the priority in managing fluid overload. Obtaining a prescription for misoprostol (
D) is unrelated to managing fluid overload.
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 4 of 5
Which of the following findings indicates a decline in the newborn's status?
Correct Answer: D
Rationale: The correct answer is D: Oxygen saturation of 89%. A low oxygen saturation level indicates poor oxygenation, which is a critical indicator of a decline in the newborn's status. Oxygen saturation below 90% is concerning and may lead to hypoxia, affecting vital functions. Nasal flaring (
A) and fine crackles (
C) can be early signs of respiratory distress but do not directly indicate a decline. An apneic episode less than 15 seconds (
B) is common in newborns and does not necessarily indicate a significant decline. In summary, a low oxygen saturation level is the most critical finding that indicates a decline in the newborn's status compared to the other choices.
Extract:
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid.
Question 5 of 5
Which of the following actions should the nurse include in the plan of care?
Correct Answer: B
Rationale: The correct answer is B: Administer broad-spectrum antibiotics. This action is appropriate for preventing or treating infection at the site. Povidone-iodine cleansing (
A) may be too harsh for the wound. Surgical closure (
C) should be based on wound assessment, not a fixed time frame. Monitoring rectal temperature (
D) is not directly related to wound care. The nurse should focus on infection prevention and treatment, making administering antibiotics the most appropriate choice.