ATI RN Maternal Newborn Updated 2023

Extract:

A postpartum client who delivered vaginally 8 hr ago.

Question 1 of 5

Select the 3 findings that require immediate follow-up.

Correct Answer: B,C,D

Rationale: The correct findings that require immediate follow-up are B: Lateral deviation of the uterus, C: Large amount of lochia rubra, and D: Uterine tone soft. Lateral deviation of the uterus could indicate a uterine anomaly or complication post-delivery. Large amount of lochia rubra may suggest excessive bleeding, which needs to be assessed promptly. Soft uterine tone can be a sign of uterine atony, a serious postpartum complication. Peripheral edema, soft breasts, low deep tendon reflexes, and mild pain rating do not typically require immediate intervention or follow-up.

Extract:

A postpartum client who has a prescription for a rubella immunization.

Question 2 of 5

Which of the following client statements indicates understanding of the teaching?

A. I should avoid breastfeeding for 2 weeks following the immunization B. I will receive a series of three immunizations and each one will be a month apart C. I will report joint pain that develops after the immunization to my provider immediately D. I should avoid becoming pregnant for at least 1 month following the immunization

Correct Answer: D

Rationale: The correct answer is D because it demonstrates understanding of the teaching regarding the need to avoid pregnancy for at least 1 month following the immunization to prevent any potential harm to the fetus.
Choice A is incorrect because breastfeeding is not contraindicated after immunization.
Choice B is incorrect because it provides incorrect information about the immunization schedule.
Choice C is incorrect because joint pain is a common side effect of some vaccines and does not necessarily require immediate reporting.

Extract:

A maternal unit policy to ensure proper identification of newborns.

Question 3 of 5

Which of the following should the nurse include in the policy?

A. Replace the infant's identification band after his name has been recorded B. Check the newborn's identification using the crib card C. Obtain an imprint of the infant's feet prior to taking him to the nursery D. Require visitors to wear an identification band

Correct Answer: C

Rationale: The correct answer is C because obtaining an imprint of the infant's feet prior to taking him to the nursery is crucial for proper identification and ensuring the right baby goes to the correct parent. This step helps prevent mix-ups and enhances patient safety.

Choice A is incorrect because replacing the infant's identification band after his name has been recorded may lead to errors in identification.

Choice B is incorrect as checking the newborn's identification using the crib card alone may not be sufficient for accurate identification.

Choice D is incorrect as requiring visitors to wear an identification band does not directly address the issue of infant identification and safety.

In summary, choice C is the most appropriate as it directly contributes to proper infant identification and reduces the risk of errors, making it the best option for inclusion in the policy.

Extract:

Parents of a newborn about the Plastibell circumcision technique.

Question 4 of 5

Which of the following information should the nurse include?

A. Yellow exudate will form at the surgical site in 24 hours B. Notify the provider if the end of your baby's penis appears dark red C. The Plastibell will be removed 4 hours after the procedure D. Make sure the newborn's diaper is snug

Correct Answer: A

Rationale: The correct answer is A because it provides important information about the expected post-operative outcome related to wound healing. Yellow exudate is a normal part of the healing process, indicating the presence of white blood cells and tissue debris. This knowledge helps the caregiver differentiate between normal and abnormal wound healing.

Choices B, C, and D are incorrect because they do not provide relevant or accurate information related to circumcision care.
Choice B refers to a potential sign of infection or poor circulation, not a routine post-circumcision finding.
Choice C inaccurately states the timing of Plastibell removal, which typically occurs after a few days, not 4 hours.
Choice D is unrelated to circumcision care and may cause discomfort if the diaper is too tight.

Extract:

A client who is experiencing an amniotic fluid embolism during labor.

Question 5 of 5

Which of the following actions should the nurse take?

A. Plan to administer ephedrine IV B. Assist the client to empty their bladder C. Assess for the presence of clonus D. Prepare to initiate cardiopulmonary resuscitation

Correct Answer: D

Rationale: The correct action for the nurse to take is to prepare to initiate cardiopulmonary resuscitation (CPR) as indicated by the situation's urgency and potential life-threatening nature. CPR is essential in cases of cardiac or respiratory arrest to maintain circulation and oxygenation. Administering ephedrine IV (
Choice
A) is not appropriate without further assessment and may not be indicated in this scenario. Assisting the client to empty their bladder (
Choice
B) is important for comfort but is not the priority over CPR. Assessing for clonus (
Choice
C) is not relevant in an emergency requiring immediate CPR.
Therefore, preparing to initiate CPR (
Choice
D) is the most critical and life-saving action to take in this situation.

ATI RN Maternal Newborn Updated 2023 | Nurselytic

Nurselytic

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