ATI RN
ATI RN Maternal Newborn 2023 II Questions
Extract:
A nurse is preparing to perform Leopold maneuvers on a client who is at 36 weeks of gestation.
Question 1 of 5
Identify the sequence of actions the nurse should take.
Correct Answer: A, B, D, E, C
Rationale: The correct order is A, B, D, E, C. Firstly, instructing the client to empty their bladder ensures a clearer examination. Positioning the client supine with knees flexed and placing a small, rolled towel under one hip helps relax the abdominal muscles for better palpation of the fundus (
D). Palpating the fetal parts along both sides of the uterus (E) helps determine the fetal position. Finally, palpating the fetal part positioned above the symphysis pubis (
C) allows for confirmation of the fetal presentation. This sequence ensures a systematic and thorough assessment of the fetal position and presentation.
Extract:
A nurse is caring for a client immediately following the delivery of a stillborn fetus.
Question 2 of 5
Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Provide the client with photos of the fetus. This action promotes bonding and helps the client cope with the loss by creating lasting memories. It allows the client to visually connect with the fetus and aids in the grieving process. Providing photos can offer comfort and closure.
Incorrect
Choices:
B: Informing the client that the law requires them to name the fetus is incorrect because there is no such legal requirement.
C: Limiting the amount of time the fetus is in the client's room may not be necessary and could hinder the client's grieving process.
D: Instructing the client that an autopsy should be performed within 24 hours is incorrect as it may not be the best timing for the client emotionally and may not be necessary in all cases.
Extract:
A nurse is assessing a newborn whose mother had gestational diabetes mellitus.
Question 3 of 5
The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?
Correct Answer: B
Rationale: The correct answer is B: Jitteriness. Jitteriness is a common manifestation of hypoglycemia due to the brain not receiving enough glucose for energy. This can lead to shakiness, nervousness, and palpitations. Abdominal distention (choice
A) is not typically associated with hypoglycemia. Petechiae (choice
C) are tiny red or purple spots on the skin due to bleeding, not related to hypoglycemia. Increased muscle tone (choice
D) is not a common sign of hypoglycemia. By monitoring for jitteriness, the nurse can promptly recognize and address hypoglycemia in the patient.
Extract:
A nurse is assessing a newborn who was born 2 hr ago and was admitted to the neonatal intensive care unit with chest wall retractions and blue discoloration of the hands and feet.
Question 4 of 5
Which of the following findings indicates a decline in the newborn's status?
Correct Answer: D
Rationale: The correct answer is D: Oxygen saturation of 89%. A low oxygen saturation level indicates poor oxygenation, which is a critical indicator of a decline in the newborn's status. Oxygen saturation below 90% is concerning and may lead to hypoxia, affecting vital functions. Nasal flaring (
A) and fine crackles (
C) can be early signs of respiratory distress but do not directly indicate a decline. An apneic episode less than 15 seconds (
B) is common in newborns and does not necessarily indicate a significant decline. In summary, a low oxygen saturation level is the most critical finding that indicates a decline in the newborn's status compared to the other choices.
Extract:
A nurse is caring for a client who is postpartum following a vaginal birth.
Question 5 of 5
Which of the following analgesic medications should the nurse plan to administer and document in the client's medical record?
Correct Answer: A
Rationale: The correct answer is A: Ibuprofen. Ibuprofen is a commonly used analgesic medication that helps relieve pain and reduce inflammation. It is safe and effective for mild to moderate pain management. As a nurse, documenting the administration of ibuprofen is important for monitoring the client's pain relief and ensuring proper medication management.
Summary of why other choices are incorrect:
B: Aspirin - While aspirin is also an analgesic, it is not typically used for pain relief due to its antiplatelet effects and potential risks of bleeding.
C: Meperidine - Meperidine is a narcotic analgesic with a high potential for abuse and adverse effects, making it less suitable for routine pain management.
D: Fentanyl citrate - Fentanyl is a potent opioid analgesic that is usually reserved for severe pain due to its high potency and risk of respiratory depression. It is not typically the first choice for pain management.