ATI RN Maternal Newborn 2023 II

Extract:

A nurse is caring for a newborn immediately following birth.

Question 1 of 5

For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?

A. The newborn weighs less than 2.5 kg (5.5 lb) B. To facilitate bonding between the newborn and parent C. To allow manifestations of infection to be identified D. The newborn was delivered via cesarean birth

Correct Answer: B

Rationale: The correct answer is B:
To facilitate bonding between the newborn and parent. Delaying the instillation of antibiotic ointment allows for crucial bonding time between the newborn and parent, promoting emotional connection and attachment. This early bonding is essential for the newborn's overall well-being and development.

Choice A is incorrect because the newborn's weight does not impact the timing of antibiotic ointment instillation.
Choice C is incorrect as delaying the ointment does not help in identifying infection manifestations.
Choice D is incorrect as the mode of delivery does not affect the timing of antibiotic ointment instillation.

Extract:

A nurse at an antepartum clinic is caring for four clients.

Question 2 of 5

Which of the following clients should the nurse assess first?

A. A client who is at 24 weeks of gestation and reports periodic tingling of the fingers B. A client who is at 36 weeks of gestation and reports back pain following intercourse C. A client who is at 8 weeks of gestation and reports severe vomiting D. A client who is at 10 weeks of gestation and reports frequent urination

Correct Answer: C

Rationale: The correct answer is C. The nurse should assess the client at 8 weeks of gestation reporting severe vomiting first as it may indicate hyperemesis gravidarum, a serious condition causing dehydration and electrolyte imbalances, risking maternal and fetal health. Severe vomiting can lead to complications like malnutrition and weight loss, affecting the developing fetus. Assessing this client first is crucial to provide immediate interventions and prevent further harm.
Other choices are less urgent: A - tingling fingers can be related to carpal tunnel syndrome common in pregnancy; B - back pain post-intercourse is common in late pregnancy due to pressure on the pelvis; D - frequent urination is a common early pregnancy symptom. These symptoms are not as concerning as severe vomiting, making choice C the priority.

Extract:

A nurse is caring for a client who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding.

Question 3 of 5

After calling for assistance and notifying the provider, which of the following actions should the nurse take next?

A. Cover the umbilical cord with a sterile saline saturated towel. B. Administer oxygen via nonrebreather mask at 8 L/min. C. Perform a vaginal examination by applying upward pressure on the presenting Ð´Ð¾Ñ€Ð¾Ð¶Ð½Ñ‹Ð¹ part. D. Initiate an infusion of IV fluids for the client.

Correct Answer: C

Rationale: The correct answer is C: Perform a vaginal examination by applying upward pressure on the presenting part. This action is crucial to assess the progress of labor, ensure proper fetal positioning, and determine if there are any complications such as cord prolapse. Administering oxygen (
B) or IV fluids (
D) may be important interventions but are not the immediate priority in this scenario. Covering the umbilical cord (
A) with a towel may increase the risk of infection.
Therefore, the key step is to perform a vaginal examination to gather essential information for appropriate decision-making.

Extract:

A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position.

Question 4 of 5

Which of the following questions should the nurse ask to evaluate the effectiveness of this intervention?

A. Do your contractions feel further apart?' B. Are you feeling relief from your pelvic pressure?' C. Has your back labor improved?' D. Does that lessen your suprapubic pain?'

Correct Answer: C

Rationale:
Rationale: The nurse should ask about the improvement in back labor as it directly evaluates the effectiveness of the intervention related to back pain relief. Contractions, pelvic pressure, and suprapubic pain are not directly related to back labor.
Therefore, asking about back labor improvement is the most relevant way to assess the intervention's success.

Extract:

A nurse is planning care for a client who is 1 hr postpartum and has peripartum cardiomyopathy.

Question 5 of 5

Which of the following actions should the nurse plan to take?

A. Restrict daily oral fluid intake. B. Administer an IV bolus of lactated Ringer's. C. Assess blood pressure twice daily. D. Obtain a prescription for misoprostol.

Correct Answer: A

Rationale: The correct answer is A: Restrict daily oral fluid intake. This is the appropriate action for a patient with fluid overload, as it helps manage fluid balance. Restricting fluid intake can prevent further fluid accumulation and complications. Administering an IV bolus of lactated Ringer's (
B) would worsen fluid overload. Assessing blood pressure twice daily (
C) is important but not the priority in managing fluid overload. Obtaining a prescription for misoprostol (
D) is unrelated to managing fluid overload.

ATI RN Maternal Newborn 2023 II | Nurselytic

Nurselytic

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