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.
Action to Take
Potential Condition
Parameter to Monitor
Correct Answer:
Rationale: Action to Take: A, B; Potential Condition: B; Parameter to Monitor: C, E. The correct answer is to place newborn skin to skin on birthing parent's chest (
A) to promote bonding and regulate temperature, and encourage breastfeeding (
B) for nutrition and immune benefits. The potential condition the client is most likely experiencing is Cold stress (
B), indicated by the need for phototherapy. The nurse should monitor Temperature (
C) for signs of hypothermia and Bilirubin level (E) to assess jaundice severity. These interventions and parameters address the client's most likely condition and provide comprehensive care.
Extract:
A nurse in a clinic is caring for a 16-year-old adolescent.
Provider Prescriptions
1300:
Standing prescriptions for clients who present with abdominal pain:
Obtain laboratory tests:
Urinalysis
Cervical culture
C-reactive protein
Beta hCG
Question 2 of 5
Which of the following findings should the nurse report to the provider? (Select all that apply.)
Correct Answer: A,B,D,E,F
Rationale: The correct findings to report to the provider are A, B, D, E, and F. A - Abdominal assessment is crucial as it can indicate underlying issues. B - Vaginal discharge can be a sign of infection or other gynecological problems. D - Temperature abnormalities can signal infection or systemic issues. E - Dyspareunia (painful intercourse) may indicate underlying conditions. F - Condom usage is important for assessing safe sex practices. These findings are relevant for the provider to assess and potentially address any health concerns.
Extract:
A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hr old.
Physical Examination:
• Fontanels soft and flat
• Head molded with caput succedaneum
• Eyes symmetric, no discharge, sclera yellow
• Mucous membranes dry
• Abdomen soft and rounded, bowel sounds present x 4 quadrants
Question 3 of 5
Which of the following findings should the nurse report to the provider? (Select all that apply.)
Correct Answer: A,B,C,G
Rationale: The correct answers to report to the provider are A, B, C, and G. A Coombs test result should be reported as it indicates potential hemolytic anemia. Mucous membrane assessment is crucial for hydration status and oxygenation. Intake and output levels are key indicators of kidney function and hydration status. Sclera color can indicate liver function or anemia.
Choices D, E, and F are important assessments but do not typically require immediate reporting unless they are outside of normal ranges and affecting the patient's condition.
Extract:
A nurse is caring for a client who is at 33 weeks of gestation.
Diagnostic Results:
• Proteinuria 3+, straw-colored urine
• Platelet count 150,000/mm3 (150,000 to 400,000/mm3)
• BUN 18 mg/dL (10 to 20 mg/dL)
Question 4 of 5
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
| Findings 24 hr later | Sign of potential worsening condition | Sign of potential improvement | Unrelated to diagnosis |
|---|---|---|---|
| Hematuria | |||
| Proteinuria 2+ | |||
| Leukorrhea | |||
| Positive clonus | |||
| BUN 40 mg/dL | |||
| Platelet count 110,000/mm3 |
Correct Answer:
Rationale:
Correct
Answer:
Rationale:
- Hematuria and Proteinuria 2+ are signs of potential worsening conditions that the nurse should interpret as concerning findings.
- Positive clonus is a sign of potential improvement, indicating a positive response to treatment.
- Leukorrhea is unrelated to the diagnosis and should not be a focus of interpretation after 24 hours.
- BUN 40 mg/dL and Platelet count 110,000/mm3 are not provided in the question and thus cannot be interpreted.
Extract:
A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
Medical History:
• Gravida 2 Para 2
• Cesarean birth
• Deep vein thrombosis with previous pregnancy
• Preeclampsia
• BMI of 32
Question 5 of 5
A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
| Findings 24 hr later | Indication of worsening condition | Indication of improving condition |
|---|---|---|
| Increased warmth in the extremity | ||
| Tachycardia | ||
| Leukocytosis | ||
| Scant lochia rubra | ||
| Decreased extremity edema |
Correct Answer:
Rationale:
Correct
Answer:
Rationale:
1. Increased warmth in the extremity (Findings 24 hr later): Deep vein thrombosis can lead to increased warmth in the affected extremity due to inflammation.
2. Tachycardia (Indication of worsening condition): Tachycardia can indicate worsening condition or potential complications such as pulmonary embolism.
3. Leukocytosis (Indication of improving condition): Leukocytosis can indicate the body's response to infection or inflammation, which may be improving.
Other
Choices:
D: Scant lochia rubra - Not relevant to the assessment of deep vein thrombosis.
E: Decreased extremity edema - Edema is not a typical finding associated with deep vein thrombosis.