ATI RN
ATI RN Maternal Newborn Updated 2023 Questions
Extract:
A client who is in labor and has a spontaneous rupture of membranes. The nurse notes that the umbilical cord is protruding from the client's vagina.
Question 1 of 5
After calling for help, which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct action is A: Use fingers to exert upward pressure on the presenting part. This is the first step in managing a prolapsed cord to alleviate pressure on the cord and prevent fetal hypoxia. Immediate action is crucial in this emergency situation. Administering tocolytic medication (
B) is not the priority as it does not address the immediate risk to the fetus. Applying oxygen via facemask (
C) is important but secondary to relieving cord compression. Wrapping the cord in a sterile towel (
D) is not recommended as it can further compress the cord.
Extract:
A client who is pregnant.
Question 2 of 5
Which of the following clinical data indicates the client is at risk for preterm delivery?
Correct Answer: B
Rationale: The correct answer is B: Previous cervical cerclage. This procedure is done to prevent preterm birth in women with a history of cervical insufficiency. The placement of a cervical cerclage indicates a higher risk for preterm delivery compared to the other options. A: Previous delivery at 37 weeks gestation is not indicative of a higher risk for preterm delivery. C: Previous reactive non-stress test is a normal finding in prenatal care and does not necessarily indicate preterm delivery risk. D: Previous delivery of a newborn weighing 2.5 kg is not a strong predictor of preterm delivery risk.
Extract:
A new parent about findings that require notification of the newborn's provider.
Question 3 of 5
Which of the following newborn clinical manifestations should the nurse include in the teaching?
Correct Answer: A
Rationale: The correct answer is A: Yellowed sclera. This clinical manifestation could indicate jaundice, a common condition in newborns due to the immature liver. It is important for the nurse to include this in teaching as it requires monitoring and potential medical intervention. Stooling after each breastfeeding (
B) is normal in newborns. Intermittent crossing of eyes (
C) is also common as their visual system develops. Voids eight to ten times per day (
D) is a normal urinary output for newborns.
Extract:
A client in the postpartum unit.
Question 4 of 5
Which of the following goals should the nurse identify for the client to accomplish during the taking-in phase of postpartum adjustment?
Correct Answer: D
Rationale: During the taking-in phase of postpartum adjustment, the focus is on the mother's own physical recovery and well-being.
Therefore, the most appropriate goal for the nurse to identify during this phase is D: The client will have adequate nutritional intake. This is crucial for the mother's own health and healing after childbirth. Proper nutrition supports her energy levels, helps with tissue repair, and aids in milk production if she chooses to breastfeed. The other choices are not as relevant during this phase. A and B are more related to infant care and safety, which are typically addressed in the later phases of postpartum adjustment. C involves family dynamics, which may be more pertinent in the later postpartum phases when the mother is more emotionally ready to focus on family roles.
Extract:
A client who is 6 hr postpartum and is saturating perineal pads every 10 to 15 min.
Question 5 of 5
Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Collect hemoglobin and hematocrit levels. This is the first action the nurse should take to assess the client's oxygen-carrying capacity and hydration status. It provides crucial data for determining the client's overall health status. Inserting an indwelling urinary catheter (
B) is not the priority unless indicated. Administering oxygen via face mask (
C) is important, but assessing the client's hemoglobin and hematocrit levels takes precedence. Preparing the client to receive a plasma expander (
D) should only be done after assessing the client's current status.