ATI RN
RN Maternal Nursing OB Newborn 2023 2024 Exam Questions
Extract:
The nurse continues to care for the client who is at 30 weeks of
gestation.
Exhiont 2
Vital Signs
1000:
Temperature 37.4"C（99.3*F)
Heart rate 90/min
Respiratory rate 20/min
Blood pressure 148/94 mm Hg
Oxygen saturation 95% on room air
1100:
Temperature 37° C (98.6° F)
Heart rate 92/min
Respiratory rate 24/min
Blood pressure 156/96 mm Hg
Oxygen saturation 94% on room air
1400:
Temperature 37.2°C（98.9*F）
Heart rate 80/min
Respiratory rate 14/min
Blood pressure 170/112 mm Hg
oxygen saturation 92% on room air
Question 1 of 5
Complete the following sentence by using the list of options. Based on the client findings, the nurse should first admister-----------------and then prepare to administer-----------------------
Correct Answer: B,A
Rationale:
Rationale:
First administer hydralazine ✅
The client is experiencing severe hypertension (BP 170/112 mm Hg at 1400), which indicates preeclampsia with severe features.
Hydralazine is a fast-acting antihypertensive that helps lower blood pressure and reduce the risk of stroke, placental abruption, or fetal compromise.
Then prepare to administer calcium gluconate ✅
If the client is receiving magnesium sulfate for seizure prevention (common in severe preeclampsia), calcium gluconate is the antidote in case of magnesium toxicity (which can cause respiratory depression or cardiac arrest).
The nurse should have calcium gluconate readily available in case of toxicity signs like loss of deep tendon reflexes, respiratory depression, or cardiac arrhythmias.
Notify the provider 🚨
The severely elevated BP (170/112 mm Hg) and potential risk for eclampsia (seizures) require immediate provider notification for further management.
Extract:
The nurse continues to care for the client who is at 30 weeks or
gestation.
Exhibit 2
Assessment
1000:
Client is Gravida 1 Para 0 and reports headache, nausea.
vomiting, and right upper abdominal pain.
Client is alert and oriented, appears restless. Client has gained
0.68 kg (1.5 lb) within the last week. Slight facial edema is
present. Heart rate regular and without murmur. Respirations
even, non-labored. Lungs clear to auscultation. Abdomen
gravid. Fundal height measurement 29 cm. 1+ dependent
edema noted bilaterally. Deep tendon reflex (DTR) is 3+
bilaterally.
Applied external fetal heart monitor. No contractions noted.
Fetal heart rate 140/min.
Question 2 of 5
Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.
Correct Answer: A,C,G
Rationale: Reposition the client (Trendelenburg or knee-chest)
Extract:
The nurse continues to care for the client who is at 30 weeks or
gestation. Exhibit1: Vital Signs
1000:
Temperature 37.4° C (99.3° F)
Heart rate 90/min|
Respiratory rate 20/min
Blood pressure 148/94 mm Hg
Oxygen saturation 95% on room air
Exhibit 2
Assessment
1000:
Client is Gravida 1 Para 0 and reports headache, nausea.
vomiting, and right upper abdominal pain.
Client is alert and oriented, appears restless. Client has gained
0.68 kg (1.5 lb) within the last week. Slight facial edema is
present. Heart rate regular and without murmur. Respirations
even, non-labored. Lungs clear to auscultation. Abdomen
gravid. Fundal height measurement 29 cm. 1+ dependent
edema noted bilaterally. Deep tendon reflex (DTR) is 3+
bilaterally.
Applied external fetal heart monitor. No contractions noted.
Fetal heart rate 140/min.
Question 3 of 5
Select the 5 findings that require follow-up by the nurse.
Correct Answer: A,C,D,E,G
Rationale: Administer oxygen
Extract:
A nurse is caring for a 36-hr old Infant
Exhibit 1
Nurses' Notes
24 hr of age:
Newborn is alert and active when awake. Respirations easy and
unlabored. Buccal membranes jaundiced. Newborn nursing
every 2 to 4 hr. Passed meconium stool. Small amount of urine
noted in diaper.
Transcutaneous bilirubin (TcB) 10 mg/dL
36 hr of age:
Newborn sleeping on birthing parent's chest. Birthing parent
reports difficulty keeping newborn awake during feedings.
Nursing every 3 to 5 hr for 10 to 15 min. Buccal membranes and
sclera jaundiced.
TcB at 36 hr 15.5 mg/dL
Question 4 of 5
The nurse is preparing the infant for phototherapy.For each nursing action, click to specify if the action is indicated or contraindicated for the newborn.
| Nursing Action | Indicated | Contraindicated |
|---|---|---|
| Supplement feeding with sterile water. | ||
| Dress in only a diaper. | ||
| Cover newborn's eyes with a shield | ||
| Apply lotion to skin every 4 Mr. | ||
| Breastfeed every 2 to 3 hr. |
Correct Answer:
Rationale: Increase IV fluids for better circulation
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.
Question 5 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: