ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
A nurse is assessing a postpartum client during a follow-up visit.
Exhibit 3 - Vital Signs
Time Vital Signs
0930 Temperature 37°C (98.6°F)
Pulse rate 78/min
Respiratory rate 12/min
Blood pressure 124/80 mm Hg
Pulse oximetry 100%
Question 1 of 5
The nurse is teaching the client about postpartum depression. The nurse should encourage the client to----------------- and ----------------- to help prevent postpartum depression.
Correct Answer: B,E
Rationale: The correct answers are B and E. Maintaining a strong support system is crucial for emotional well-being, as it provides the client with reassurance, understanding, and help in times of need. This can help prevent feelings of isolation and loneliness, common in postpartum depression. Additionally, exercising for at least 30 minutes per day can release endorphins, improve mood, and reduce stress, all of which can contribute to preventing postpartum depression.
Choices A, C, and D are important for overall health but do not specifically address the emotional and mental aspects that can lead to postpartum depression.
Extract:
Question 2 of 5
A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?
Correct Answer: B
Rationale: The correct answer is B: Transmission can occur via the saliva and urine of the newborn. Cytomegalovirus (CMV) can be transmitted through bodily fluids such as saliva, urine, blood, and breast milk. This is important information for nurses to be aware of as they care for newborns who may be infected.
Explanation for other choices:
A: Mothers do not receive prophylactic treatment with acyclovir for CMV, as there is no specific antiviral treatment for this virus.
C: Lesions on the mother's genitalia are not a typical feature of CMV infection.
D: Airborne precautions are not required for CMV as it is primarily transmitted through bodily fluids, not through the air.
Question 3 of 5
A nurse is assessing a newborn following a forceps-assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of this birth method?
Correct Answer: D
Rationale: The correct answer is D: Facial palsy. Forceps-assisted birth can lead to pressure on the facial nerve, resulting in facial nerve injury and facial palsy in the newborn. This can manifest as weakness or paralysis of facial muscles. Polycythemia (
A) is not typically associated with forceps-assisted birth. Hypoglycemia (
B) may occur due to various reasons but is not directly related to the birth method. Bronchopulmonary dysplasia (
C) is a lung condition often seen in premature infants on long-term ventilation. In summary, facial palsy is a potential complication of forceps-assisted birth due to nerve compression, while the other options are less likely to be directly linked to this birth method.
Question 4 of 5
A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply.)
Correct Answer: A,C,D
Rationale: The correct answer choices, A, C, and D, all contribute to an increased risk of postpartum hemorrhage. A, labor induction with oxytocin, can lead to uterine hyperstimulation, increasing the risk of postpartum hemorrhage. C, vacuum-assisted delivery, may cause trauma to the birth canal, leading to increased bleeding. D, history of uterine atony, indicates a previous inability of the uterus to contract effectively, which is a major risk factor for postpartum hemorrhage.
Therefore, these factors collectively place the client at a higher risk for postpartum hemorrhage.
Choices B and E are incorrect as they do not directly relate to the risk of postpartum hemorrhage.
Question 5 of 5
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?
Correct Answer: A
Rationale: The correct answer is A: Administer broad-spectrum antibiotics. This is crucial to prevent infection in the exposed neural tissue. Myelomeningocele increases the risk of meningitis due to the breach in the protective layers of the spinal cord. Administering antibiotics helps to prevent bacterial invasion and subsequent infection. Monitoring rectal temperature is not directly related to the myelomeningocele issue. Cleaning the site with povidone-iodine may cause further irritation to the exposed tissue. Immediate surgical closure is usually necessary to prevent infection; waiting 72 hours is not appropriate in this case.