ATI LPN
ATI PN Maternal Newborn 2023 II Questions
Extract:
A nurse is obtaining a capillary blood sample from a newborn for phenylketonuria testing.
Question 1 of 5
Identify the sequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Correct Answer: E,A,C,D,B
Rationale: 1. Wrap a warm, moist cloth around the heel. 2. Cleanse the heel with an antiseptic. 3. Puncture the heel and collect the blood. 4. Apply pressure with a dry gauze pad. 5. Cover the heel with an adhesive bandage.
Extract:
A nurse is reinforcing teaching with a client who is at 38 weeks of gestation and has a positive group B streptococcus B-hemolytic screening.
Question 2 of 5
Which of the following medications should the nurse discuss as the prophylaxis treatment during labor for this client?
Correct Answer: A
Rationale: Penicillin is the recommended prophylactic treatment for a client at 38 weeks of gestation with a positive group B streptococcus B-hemolytic screening. It is highly effective in preventing the transmission of group B strep from mother to baby during labor and delivery. Administering Penicillin reduces the risk of neonatal sepsis, pneumonia, and meningitis caused by group B strep.
Extract:
A nurse is reinforcing teaching to a client who will undergo amniocentesis.
Question 3 of 5
Which of the following statements should the nurse make?
Correct Answer: A
Rationale: Amniocentesis is used to detect fetal genetic abnormalities, such as Down syndrome, by analyzing the amniotic fluid for genetic markers.
Extract:
A nurse is reinforcing discharge teaching about breastfeeding with a client.
Question 4 of 5
Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: C
Rationale: Feeding the baby for 30 minutes during each feeding is correct. This duration allows adequate time for the baby to receive both foremilk and hindmilk, which is essential for nutrition and satiety.
Extract:
Vital Signs 0700: Temperature: 36.2°C (97.2°F), Heart rate: 80/min, Respiratory rate: 16/min, Blood pressure: 136/82 mm Hg. 1100: Temperature: 37.2°C (99.0°F), Heart rate: 85/min, Respiratory rate: 18/min, Blood pressure: 136/86 mm Hg, Pulse oximetry: 99%. Nurses' Notes 0700: The client's breasts were soft, and nipples were intact. The uterus was palpated as firm, midline, and at the level of the umbilicus. There was a moderate amount of lochia rubra. The episiotomy site was well approximated with mild edema and ecchymosis. The client reported pain as 2 on a scale of 0 to 10. She was able to void spontaneously, with no bladder distention. Deep tendon reflexes were 1+. Peripheral edema was 2+ in bilateral lower extremities. 1100: The client's breasts remained soft, and nipples were intact. The uterus was palpated as soft with lateral deviation and 1 cm above the umbilicus. There was a large amount of lochia rubra. The episiotomy site was well approximated with mild edema and ecchymosis. The client reported pain as 3 on a scale of 0 to 10. Deep tendon reflexes were 1+. Peripheral edema was 2+ in bilateral lower extremities.
Question 5 of 5
Select the 3 findings that require immediate follow-up.
Correct Answer: B,F,G
Rationale: Lateral deviation of the uterus can indicate bladder distension, which can interfere with uterine contraction and increase the risk of postpartum hemorrhage. A soft uterine tone indicates uterine atony, which can lead to postpartum hemorrhage. A large amount of lochia rubra can be a sign of postpartum hemorrhage.