ATI RN
ATI RN Maternal Newborn 2023 II Questions
Extract:
A nurse is preparing to obtain a blood sample from a newborn's heel.
Question 1 of 5
In what order should the nurse perform the procedure?
Correct Answer: A, B, C, D, E
Rationale: The correct order for the nurse to perform the procedure is A, B, C, D, E. First, applying a warm cloth to the newborn's heel for 5 to 10 min helps dilate the blood vessels for easier blood collection. Second, cleaning the area with an antiseptic prevents infection during the puncture. Third, puncturing the outer aspect of the newborn's heel allows for blood collection. Fourth, collecting the blood specimen is the main objective of the procedure. Finally, applying pressure to the site with a dry gauze pad helps stop bleeding and promotes healing.
Choices F and G are not provided in the question, so they are not applicable.
Extract:
A nurse is caring for a client who is 1 hr postpartum and has uterine atony. The client is exhibiting a large amount of vaginal bleeding.
Question 2 of 5
Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct action for the nurse to take is to anticipate a prescription for misoprostol (
Choice
D) for a patient. This is because misoprostol is commonly prescribed in obstetric practice for various indications, such as induction of labor, management of postpartum hemorrhage, and treatment of incomplete abortion. Anticipating this prescription allows the nurse to be prepared for the medication administration process, including understanding the dosage, route of administration, potential side effects, and monitoring requirements.
Choice A is incorrect as obtaining a specimen for a Kleihauer-Betke test is not the immediate action required based on the scenario provided.
Choice B, administering betamethasone IM, is also incorrect as it is not the appropriate action indicated in the situation described.
Choice C, avoiding performing sterile vaginal examinations, is not relevant to the given scenario and does not address the patient's immediate needs.
Extract:
A nurse in a prenatal clinic is caring for a group of clients.
Question 3 of 5
The nurse should recognize that which of the following clients has a contraindication for a contraction stress test?
Correct Answer: B
Rationale: The correct answer is B because a client with a previous classical incision (vertical uterine incision) is at risk for uterine rupture during a contraction stress test due to the weakened uterine wall. A uterine rupture can lead to severe complications for both the mother and the baby. Clients with previous classical incisions should not undergo contraction stress tests.
Choice A is incorrect because a previous stillbirth is not a contraindication for a contraction stress test.
Choice C is incorrect as gestational diabetes mellitus alone is not a contraindication for the test.
Choice D is also incorrect as a nonreactive nonstress test does not directly contraindicate a contraction stress test.
Extract:
A nurse is preparing to perform Leopold maneuvers on a client who is at 36 weeks of gestation.
Question 4 of 5
Identify the sequence of actions the nurse should take.
Order the Items
Source Container
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 obtaining a 2-hr postprandial blood glucose from a client.
Question 5 of 5
Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Select the lateral side of the finger for puncture. This is because the lateral side has fewer nerve endings, making it less painful for the patient. Puncturing the finger on the lateral side also helps to avoid the central pad where blood flow is better. Holding the finger above the heart (choice
B) is incorrect as it can increase blood flow and dilute the sample. Smearing blood onto the reagent strip (choice
C) is incorrect as it can lead to inaccurate results. Puncturing the finger while still damp with antiseptic solution (choice
D) is incorrect as it can contaminate the blood sample.