ATI RN
ATI RN Maternal Newborn 2023 IV Questions
Extract:
A nurse is assessing the newborn 24 hr later after a vacuum-assisted vaginal birth. Maternal GBS positive, received ampicillin. Apgar: HR 96/min, weak cry, some flexion, grimace, acrocyanosis, Temp 36.9°C. Labs: WBC 15,000/mm³, Hgb 19 g/dL, Hct 57%, Glucose 44 mg/dL.
Question 1 of 5
How should the nurse interpret the findings? (For each finding, specify if unrelated, improving, or worsening.)
Correct Answer: A
Rationale: A: Flaccid tone (worsening) suggests decline from 'some flexion'. B: Color consistent (unrelated) is normal variation. C: HR 140 bpm (improving) is better than 96/min. D: Temp 36.9°C (unrelated) is stable and normal.
Extract:
A nurse is caring for a client who is postpartum and has a perineal laceration.
Question 2 of 5
Which of the following findings places the client at risk for delayed wound healing?
Correct Answer: C
Rationale: Changing the perineal pad only once daily increases infection risk due to moisture buildup, delaying healing. Cleaning, approximation, and witch hazel support healing.
Extract:
A nurse is planning care for a client in the postpartum unit.
Question 3 of 5
Which of the following goals should the nurse identify for the client to accomplish during the taking-in phase of postpartum adjustment?
Correct Answer: D
Rationale: During the taking-in phase, the focus is on maternal recovery, making adequate nutritional intake a key goal for healing and breastfeeding support.
Extract:
A nurse is preparing to administer phytonadione 0.5 mg to a newborn.
Question 4 of 5
Which of the following routes should the nurse choose for administration of the medication?
Correct Answer: C
Rationale: The vastus lateralis muscle in the thigh is the preferred site for IM injections in newborns due to its size and accessibility. Phytonadione (Vitamin K) is administered IM, not subcutaneously, and the deltoid is not used in newborns.
Extract:
A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hr old.
Nurses' Notes
Term newborn birthed via spontaneous vaginal delivery at 39 weeks of gestation. Apgar 9/9 at 5-minute score. Breastfeeding 3 to 4 times per day. Newborn has voided once since birth and has not passed meconium stool since birth.
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
Vital Signs
• Heart rate 154/min
• Respiratory rate 44/min
• Temperature 36.9° C (98.4° F)
Diagnostic Results
• Coombs positive (negative)
• Glucose 50 mg/dL (40 to 60 mg/dL)
Question 5 of 5
Which finding(s) from the assessment should be reported to the provider for further evaluation or intervention? Select all that apply.
Correct Answer: A, B, D
Rationale: Dry mucous membranes (
A) and low output (
D) suggest dehydration from inadequate feeding (3-4 times/day vs. 8-12). Yellow sclera (
B) indicates jaundice, needing bilirubin checks.