ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake 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)
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.
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:
1. The potential condition the client is most likely experiencing is Acute bilirubin encephalopathy .
2. The nurse should take the actions of placing the newborn skin to skin on the birthing parent's chest and encouraging breastfeeding to address this condition.
3. Parameters to monitor include monitoring temperature (to assess for hypothermia related to cold stress) and monitoring the bilirubin level (to assess for bilirubin encephalopathy progression).
Summary:
-
Choice A is incorrect as obtaining a prescription for arterial blood gases and planning phototherapy are not directly related to the potential condition.
-
Choice C is incorrect as monitoring stool output, lung sounds, and blood glucose level are not specific to the potential condition identified.
- It's essential to focus on actions and parameters directly related to the identified potential condition for effective client care.
Extract:
Question 2 of 5
A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Verify the newborn's identification. This is the first action the nurse should take because ensuring the correct identification of the newborn is crucial for providing safe and effective care. Without proper identification, there is a risk of administering medications or treatments to the wrong newborn. Confirming the newborn's Apgar score can be important but is not as time-sensitive as verifying identification. Administering vitamin K and determining obstetrical risk factors are important tasks but should come after verifying the newborn's identification to ensure the safety of the care provided.
Extract:
A nurse is caring for a client who is experiencing a postpartum hemorrhage and has a new prescription for misoprostol.
Exhibit 2: Medical History
Preeclampsia
Cesarean birth of viable twin male newborns
Question 3 of 5
The nurse is assessing the client 30 min later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
| Findings 30 min later | Unrelated to diagnosis | Indication Of potential improvement | Indication of Potential worsening condition |
|---|---|---|---|
| Fundus at level of umbilicus | |||
| Cloudy urine | |||
| Blood pressure 80/50 mm Hg | |||
| Moderate lochia rubra | |||
| Thready pulse | |||
| Fundus firm to palpation |
Correct Answer:
Rationale:
Correct Answer:
Rationale:
- Fundus at the level of the umbilicus is an indication of potential improvement as it indicates proper involution of the uterus.
- Cloudy urine is unrelated to the diagnosis and may indicate other issues like urinary tract infection.
- Blood pressure of 80/50 mm Hg is an indication of potential worsening condition as it is hypotensive.
- Moderate lochia rubra is also an indication of potential worsening condition as it may indicate excessive bleeding.
- Thready pulse is unrelated to the diagnosis.
- Fundus firm to palpation is an indication of potential improvement as it indicates proper uterine contraction and involution.
Extract:
Question 4 of 5
A nurse is caring for a client who is receiving an epidural block with an opioid analgesic. The nurse should monitor for which of the following findings as an adverse effect of the medication?
Correct Answer: C
Rationale: The correct answer is C: Hypotension. Epidural opioids can cause vasodilation, leading to a drop in blood pressure. This can result in hypotension, which the nurse should monitor for due to the risk of complications. Hyperglycemia (
A), bilateral crackles (
B), and polyuria (
D) are not typically associated with epidural opioids. Hyperglycemia is more commonly linked to stress or certain medications. Bilateral crackles suggest pulmonary issues, not related to epidural opioids. Polyuria is excessive urine production, not a common adverse effect of epidural opioids.
Question 5 of 5
A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?
Correct Answer: C
Rationale: The correct answer is C: Administer Rho(
D) immune globulin. This is the priority intervention because the client is Rh-negative, and an amniocentesis can lead to fetal-maternal blood incompatibility. Administration of Rho(
D) immune globulin helps prevent the mother from developing antibodies against Rh-positive fetal blood cells, reducing the risk of hemolytic disease in the fetus. Checking the client's temperature (
A) is important but not the priority immediately following an amniocentesis. Observing for uterine contractions (
B) is not the priority unless there are signs of preterm labor. Monitoring the FHR (
D) is essential but not the priority immediately post-amniocentesis.