ATI RN
RN ATI Maternal Newborn 2023 with NGN Questions
Extract:
A nurse is caring for a newborn who is 48 hr old.
Exhibit 1
Vital Signs
Day 2, 0900:
Heart rate 174/min
Respiratory rate 88/min
Temperature 36.1° C (97.0° F)
Oxygen saturation 97% on room air
Exhibit 2
Diagnostic Results
Day 1, 0800: Newborn results
Blood type: A+
Urine toxicology screen: positive marijuana
Day 2, 0800: Newborn results
Total bilirubin 10 mg/dL (1.0 to 12.0 mg/dL)
Day 2, 0915:
Blood glucose: 38 mg/dL (expected value greater than 40 to 45
gm/dL
Exhibit 3
Nurses Notes
Day 2, 0900:
Newborn awake, alert, and crying. Loosely wrapped in one
blanket. Mild tremors noted. Yellow discoloration of mucus
membranes and sclera noted. Respirations 88/min, no
retractions, grunting, or nasal flaring noted. Diaper changed for
small amount of urine and transitional stool. Exhibit 4
Medical History
Apgars: 7 at 1 min and 8 at 5 min of age
Birth weight: 3,515 g (7 lb 12 oz)
Maternal blood type: O+
Uncomplicated pregnancy. Maternal use of marijuana during
pregnancy
Client who gave birth plans to breastfeed.
Question 1 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Correct Answer:
Rationale: Action to Take: A, B; Potential Condition: B; Parameter to Monitor: C, E.
Rationale: The correct answer is to place newborn skin to skin on birthing parent's chest and encourage breastfeeding to address potential condition of Cold stress. Parameters to monitor are temperature and bilirubin level. Skin-to-skin contact and breastfeeding help regulate newborn's temperature and decrease risk of hypothermia. Cold stress can lead to increased bilirubin levels, so monitoring temperature and bilirubin levels will help assess the baby's progress. Incorrect options: Option A focuses on phototherapy and neonatal abstinence system scoring, which are not indicated for cold stress. Option C includes stool output and lung sounds, which are not relevant for assessing cold stress.
Extract:
Question 2 of 5
A nurse is caring for a client who is to receive oxytocin to augment their labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
Correct Answer: A
Rationale: The correct answer is A: Late decelerations. Late decelerations indicate uteroplacental insufficiency, which can lead to fetal distress. Oxytocin can further decrease uteroplacental perfusion, worsening the late decelerations. This finding should be reported to the provider immediately to prevent fetal compromise.
Incorrect choices:
B: Moderate variability of the FHR is a reassuring sign of fetal well-being and does not contraindicate the initiation of oxytocin.
C: Cessation of uterine dilation may indicate a prolonged labor but is not a contraindication for oxytocin infusion.
D: Prolonged active phase of labor may require augmentation with oxytocin, so it is not a contraindication on its own.
Question 3 of 5
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on bed rest. This is important to prevent dislodgement of the clot and further complications associated with thrombophlebitis. Moving the client around can increase the risk of clot migration. Administering aspirin for pain (choice
A) is not appropriate as it can increase the risk of bleeding with heparin therapy. Massaging the affected leg every 12 hours (choice
C) can also dislodge the clot and is contraindicated. Applying cold compresses to the affected calf (choice
D) can also increase the risk of clot dislodgement.
Therefore, the best action is to maintain the client on bed rest to minimize the risk of complications.
Question 4 of 5
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?
Correct Answer: D
Rationale: The correct answer is D: Instruct the client to press the provided button each time fetal movement is detected. This action is crucial during a nonstress test as it helps monitor fetal heart rate in response to movement, indicating a healthy fetal status. Pressing the button when fetal movement is felt ensures accurate data collection. Maintaining NPO status (
A) is not required for a nonstress test. Placing the client in a supine position (
B) can reduce blood flow to the fetus and is contraindicated. Instructing the client to massage the abdomen (
C) may interfere with the natural fetal movement patterns and affect test results.
Question 5 of 5
A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?
Correct Answer: B
Rationale: The correct answer is B: Leakage of fluid from the vagina. Following an amniocentesis, leakage of amniotic fluid from the vagina can indicate a potential complication such as amniotic fluid leakage, which can lead to preterm labor or infection. This finding should be reported to the provider promptly for further evaluation and management. Increased fetal movement (choice
A) is a normal occurrence and not typically concerning. Upper abdominal discomfort (choice
C) is common after the procedure due to stretching of the uterus but does not necessarily indicate a complication. Urinary frequency (choice
D) is not directly related to amniocentesis complications.