ATI RN
ATI Maternal Newborn Proctored Exam Latest Update Questions
Extract:
Question 1 of 5
Which assessment finding indicates that placental separation has occurred during the third stage of labor?
Correct Answer: D
Rationale: The correct answer is D: Lengthening of the umbilical cord. This is indicative of placental separation because as the placenta detaches from the uterine wall, the cord lengthens due to the release of tension. This signals successful completion of the third stage of labor.
Incorrect choices:
A: Decreased vaginal bleeding is not a reliable indicator of placental separation.
B: Contractions stopping may occur after the placenta is delivered, but it is not a definitive sign of placental separation.
C: Maternal shaking and chills can be caused by various factors and are not specific to placental separation.
Question 2 of 5
During the first twelve hours following a normal vaginal delivery, the client voids 2,000 mL of urine. How should the nurse interpret this finding?
Correct Answer: D
Rationale: The correct interpretation is D: Normal diuresis after delivery. After childbirth, the body eliminates excess fluid accumulated during pregnancy, leading to increased urine output. This process, known as diuresis, helps to reduce swelling and prevent fluid retention. Voiding 2,000 mL of urine in the first 12 hours is within the expected range for postpartum diuresis.
A: Urinary tract infection - There are no symptoms or signs indicating a urinary tract infection.
B: High output renal failure - This condition is characterized by decreased urine output, not increased.
C: Excessive use of IV fluids during delivery - Excessive IV fluids would not lead to such significant diuresis immediately post-delivery.
In summary, the significant urine output post-vaginal delivery is indicative of normal postpartum diuresis, not any pathological condition.
Question 3 of 5
Which site is preferred for giving an IM injection to a newborn?
Correct Answer: B
Rationale: The correct answer is B: Vastus lateralis. This site is preferred for giving an IM injection to a newborn because it has a large muscle mass and is easily accessible. The vastus lateralis muscle is located on the lateral side of the thigh, making it a safe and effective site for administering injections in infants. It is important to avoid other sites like the ventrogluteal, rectus femoris, or dorsogluteal in newborns due to the risk of hitting nerves or blood vessels. The vastus lateralis is the most recommended site for IM injections in infants for safety and efficacy.
Question 4 of 5
A nurse is preparing to take a rectal temperature on a 7-month-old infant. Which of the following should the nurse keep in mind when preparing to take the temperature?
Correct Answer: B
Rationale:
Correct Answer: B
Rationale: The correct answer is B because rectal temperatures are typically 1.5-2°F higher than oral temperatures due to the body's core temperature being higher internally. This conversion is essential in accurately interpreting the infant's rectal temperature.
Summary of other choices:
A: Incorrect. The maximum insertion depth for a rectal thermometer in infants is 1 inch, not 2.5 inches.
C: Incorrect. Rectal temperatures are not the only accurate method for infants; axillary or temporal artery thermometers are also reliable.
D: Incorrect. Mercury thermometers are no longer recommended due to the risk of mercury exposure, and the time required to obtain a rectal temperature is typically shorter.
Question 5 of 5
A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, ''happy one min and crying the next.'' The nurse should interpret the client's statement as an indication of which of the following?
Correct Answer: A
Rationale: The correct answer is A: Emotional lability. Emotional lability refers to rapid and unpredictable changes in emotions, such as going from happy to crying quickly. This is a common experience during pregnancy due to hormonal fluctuations. Focusing phase (
B) refers to a stage of problem-solving, not emotional state. Cognitive restructuring (
C) involves changing negative thought patterns. Couvade syndrome (
D) is when a partner experiences pregnancy-like symptoms.
Choices E, F, and G are not relevant to the client's statement.