ATI RN
RN ATI Maternal Newborn 2023 with NGN Questions
Extract:
A nurse is caring for a postpartum client in an outpatient setting
Exhibit1:
History and Physical
G1P1, spontaneous vaginal delivery with median episiotomy at 39 weeks of gestation.
Newborn 4,508 g (9 lb 15 oz), APGARs: 8 at 1 min, 9 at 5 min
group B streptococcus 8-hemolytic: positive (negative)
Received 2 doses of Intravenous penicillin G while in labor”
Question 1 of 5
complete the following sentence by using the lists of options. The client is at highest risk for developing ---evidenced by the client's ---
| Endometritis. |
| Mastitis. |
| Postpartum hemorrhage. |
| Group B streptococcus positive status. |
| Spontaneous vaginal delivery. |
| Median episiotomy. |
Correct Answer: A
Rationale:
To determine the correct answer, we need to consider the highest risk based on the client's condition. Endometritis is the most likely complication after childbirth due to factors like prolonged labor, multiple vaginal exams, and retained placental fragments. The client's presentation with signs such as fever, uterine tenderness, and foul-smelling vaginal discharge supports this diagnosis. Mastitis, postpartum hemorrhage, and Group B streptococcus positivity are also potential complications but are typically associated with different risk factors and clinical manifestations. Spontaneous vaginal delivery and median episiotomy are procedures or events during labor and delivery that may not directly relate to the development of endometritis.
Therefore, based on the client's symptoms and risk factors, the correct answer is A: Endometritis.
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 2 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:
“A nurse on an antepartum unit is caring for a client.
Exhibit1:
Nurses' Notes 0900:Client reports a small amount of bright red blood in their underwear upon
awakening. Client denies contractions or abdominal pain. External fetal monitor applied.
0930:Client passed large amount of bright red blood from vagina.
Denies pain Uterine tone soft and nontender to palpation.
contraction pattern, no contractions noted.
Fetal heart rate pattern: Fetal heart rate baseline 135/min.
Moderate variability. No decelerations noted.
Exhibit2:
Vital Signs 0900: Temperature 36.2°C (97.2° F) Pulse rate 78/min Respiratory rate 20/min Blood pressure
112/64 mm Hg Fetal heart rate 132/min Pulse rate 82/min Blood pressure 116/60 mm Hg Fetal heart
rate 160/min
Exhibit3:
Medical History. G4P3 30 weeks gestation Previous pregnancies delivered via cesarean section
Question 3 of 5
Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify it the intervention is indicated or contraindicated for the client.
| Potential Nursing Action | Indicated | Contraindicated | |
|---|---|---|---|
| Insert a large bore intravenous catheter. | |||
| Assess cervical dilation. | |||
| Weigh perineal pads. | |||
| Administer methotrexate. |
Correct Answer: A, C
Rationale: , (B, 0, 1, 0), (C, 1, 0, 1), (D, 0, 0, 0)
- A: Inserting a large bore IV catheter is indicated for emergency situations to provide rapid fluid replacement or administer medications.
- B: Assessing cervical dilation is not indicated unless specifically related to the client's condition, not a routine nursing action.
- C: Weighing perineal pads is indicated to monitor postpartum hemorrhage by measuring blood loss.
- D: Administering methotrexate is contraindicated in the absence of a specific indication or prescription for the client.
Extract:
Question 4 of 5
A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?
Correct Answer: D
Rationale: The correct answer is D: Vomiting. Neonatal withdrawal from SSRIs can present with symptoms such as jitteriness, irritability, poor feeding, and gastrointestinal symptoms like vomiting. This is due to the sudden cessation of the drug after birth, leading to withdrawal symptoms. The other choices are incorrect because large for gestational age (
A) is not typically associated with SSRI withdrawal; hyperglycemia (
B) is not a common withdrawal symptom; bradypnea (
C) is not a typical manifestation of SSRI withdrawal.
Question 5 of 5
A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
Correct Answer: B
Rationale: The correct answer is B: Temperature. Amniotomy involves breaking the amniotic sac, increasing the risk of infection. Monitoring the client's temperature is crucial to detect early signs of infection, such as fever. Maintaining a normal temperature is essential to prevent maternal and fetal complications. O2 saturation, blood pressure, and urinary output are important assessments but do not take priority over monitoring the client's temperature post-amniotomy.