ATI RN
ATI RN Maternal Newborn 2023 IV Questions
Extract:
A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hr old.
Nurses' Notes
Term newborn birthed via spontaneous vaginal delivery at 39 weeks of gestation. Apgar 9/9 at 5-minute score. Breastfeeding 3 to 4 times per day. Newborn has voided once since birth and has not passed meconium stool since birth.
Physical Examination
• Fontanels soft and flat
• Head molded with caput succedaneum
• Eyes symmetric, no discharge, sclera yellow
• Mucous membranes dry
• Abdomen soft and rounded, bowel sounds present x 4 quadrants
Vital Signs
• Heart rate 154/min
• Respiratory rate 44/min
• Temperature 36.9° C (98.4° F)
Diagnostic Results
• Coombs positive (negative)
• Glucose 50 mg/dL (40 to 60 mg/dL)
Question 1 of 5
Which finding(s) from the assessment should be reported to the provider for further evaluation or intervention? Select all that apply.
Correct Answer: A, B, D
Rationale: Dry mucous membranes (
A) and low output (
D) suggest dehydration from inadequate feeding (3-4 times/day vs. 8-12). Yellow sclera (
B) indicates jaundice, needing bilirubin checks.
Extract:
A nurse is preparing to perform a heel stick on a newborn who has a prescription for a total serum bilirubin.
Question 2 of 5
Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Puncturing the lateral heel minimizes nerve damage and ensures a good blood sample, standard for heel sticks in newborns.
Extract:
A nurse is planning care for a client in the postpartum unit.
Question 3 of 5
Which of the following goals should the nurse identify for the client to accomplish during the taking-in phase of postpartum adjustment?
Correct Answer: D
Rationale: During the taking-in phase, the focus is on maternal recovery, making adequate nutritional intake a key goal for healing and breastfeeding support.
Extract:
A nurse is caring for a client in labor who has herpes simplex virus (HSV) with active lesions.
Question 4 of 5
Which of the following interventions should the nurse plan to implement to prevent the transmission of HSV to the newborn?
Correct Answer: C
Rationale: A cesarean birth prevents neonatal HSV transmission by avoiding contact with active lesions in the birth canal.
Extract:
A nurse is planning care for a client who is 1 hr postpartum and has preeclampsia without severe features.
Question 5 of 5
Which of the following actions should the nurse plan to take?
Correct Answer: A
Rationale: Assessing for edema monitors for worsening preeclampsia, a key action in the early postpartum period. Fluid bolus, restriction, and misoprostol are not indicated without severe features.