Questions 58

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ATI NUR209 Maternal Newborn Final Assessment 2025 Questions

Extract:

Child in heart failure


Question 1 of 5

Which assessment findings would alert the nurse to an infant or child in heart failure?

Correct Answer: A,B,C,D

Rationale: Difficulty feeding (
A), wheezes/rales (
B), edema (
C), and tachypnea (
D) indicate heart failure due to fatigue, pulmonary congestion, venous congestion, and compensatory respiratory efforts, respectively, reflecting poor cardiac output.

Extract:

2-month-old infant brought to the emergency room


Question 2 of 5

A 2-month-old infant is brought to the emergency room. Which factor should lead the RN to suspect that the child may have experienced abusive head trauma?

Correct Answer: B

Rationale: Retinal hemorrhages are strongly associated with abusive head trauma due to shearing forces during shaking or impact, rupturing retinal blood vessels. This is a hallmark of non-accidental trauma in infants, unlike sunken fontanels (dehydration), bruises (non-specific), or lacerations (accidental or other abuse).

Extract:

Laboring client with ruptured membranes, frequent contractions, and bloody show


Question 3 of 5

The nurse is caring for a laboring client who presents with ruptured membranes, frequent contractions, and bloody show. Which intervention should be performed first?

Correct Answer: C

Rationale: Obtaining fetal heart rate first assesses fetal well-being post-membrane rupture and contractions. Vaginal exams risk infection, IV access and vital signs are secondary to ensuring fetal oxygenation.

Extract:

Pregnant patient with elevated alpha fetoprotein (AFP) level


Question 4 of 5

Which statement made by a pregnant patient indicates teaching was effective related to an elevated alpha fetoprotein (AFP) level?

Correct Answer: B

Rationale: Elevated AFP suggests neural tube defects like spina bifida, not Down syndrome, which typically shows decreased AFP. 'May have' reflects the need for further testing, indicating accurate understanding.

Extract:


Question 5 of 5

Which of the following clients would the nurse report as a suspected abuse case?

Correct Answer: B,C,D

Rationale: Circular abrasions (
B), palm burn (
C), and splash burns (
D) suggest intentional injury patterns (binding, forced contact, scalding), warranting abuse reporting. A forehead bruise (
A) may be accidental in a mobile toddler.

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