ATI RN
ATI RN Maternal Newborn Updated 2023 Questions
Extract:
A client who delivered by cesarean birth 6 hr ago.
Question 1 of 5
The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Administer 500 mL lactated Ringer's IV bolus. This action is necessary to address potential hypovolemia due to the steady vaginal bleeding. Lactated Ringer's solution helps restore intravascular volume and maintain perfusion. Evaluating urinary output (
A) is important but not the priority when immediate action is needed. Replacing the surgical dressing (
B) is not the first step in managing ongoing bleeding. Applying an ice pack to the incision site (
C) is not indicated and may not address the underlying issue.
Extract:
A client who is taking an oral contraceptive.
Question 2 of 5
The nurse should instruct the client to report which of the following findings to the provider immediately?
Correct Answer: B
Rationale: The correct answer is B: Persistent headaches. Headaches can indicate serious conditions like hypertension or preeclampsia, requiring immediate medical attention to prevent complications. Breast tenderness, vaginal itching, and painful intercourse are common discomforts during pregnancy but typically not urgent issues. Reporting persistent headaches promptly can ensure timely intervention and prevent potential risks to the client and fetus.
Extract:
A client who is experiencing infertility and is requesting in vitro fertilization.
Question 3 of 5
Which of the following information should the nurse provide to the client?
Correct Answer: B
Rationale: The correct answer is B: Inform the client about the possible need for the reduction of multiple fetuses. This information is crucial in cases of multiple pregnancies to ensure the client is aware of the potential risks and options available. Reduction of multiple fetuses may be necessary for the health and safety of both the mother and babies. Providing this information allows the client to make informed decisions regarding their pregnancy.
Choices A, C, and D are incorrect because they do not address the specific concern of managing multiple pregnancies or the potential need for fetal reduction. It is important for the nurse to prioritize relevant and essential information for the client's understanding and decision-making process.
Extract:
A client who is in labor and has a spontaneous rupture of membranes. The nurse notes that the umbilical cord is protruding from the client's vagina.
Question 4 of 5
After calling for help, which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct action is A: Use fingers to exert upward pressure on the presenting part. This is the first step in managing a prolapsed cord to alleviate pressure on the cord and prevent fetal hypoxia. Immediate action is crucial in this emergency situation. Administering tocolytic medication (
B) is not the priority as it does not address the immediate risk to the fetus. Applying oxygen via facemask (
C) is important but secondary to relieving cord compression. Wrapping the cord in a sterile towel (
D) is not recommended as it can further compress the cord.
Extract:
A newborn who has a prescription for a total serum bilirubin.
Question 5 of 5
Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct action is to puncture the lateral side of the heel for the procedure. This is because the lateral side of the heel is the recommended site for a heel stick, as it has fewer nerve endings and blood vessels, reducing the risk of injury and pain. Selecting a 21-gauge needle (option
A) is not specific to the procedure and may not be appropriate. Applying an alcohol pad after the procedure (option
B) is not recommended as it can cause unnecessary pain and irritation. Placing a cool cloth at the site before the procedure (option
C) is not necessary and may not be effective for pain relief. Puncturing the lateral side of the heel is the correct and most appropriate action for this procedure.