ATI RN
ATI RN Maternal Newborn 2023 Questions
Extract:
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid.
Question 1 of 5
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 essential in the plan of care to treat a suspected infection. Antibiotics can target a wide range of bacteria, covering potential pathogens until specific cultures can identify the causative organism. Cleansing the site with povidone-iodine (
B) is important for local hygiene but does not address systemic infection. Monitoring rectal temperature (
C) is a good assessment measure but does not actively treat infection. Preparing for surgical closure after 72 hr (
D) may be necessary but does not address the immediate need to manage infection.
Extract:
A nurse is administering a hepatitis B vaccine to a newborn.
Question 2 of 5
Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Administer the injection into the vastus lateralis muscle. This is the correct action because the vastus lateralis muscle is a recommended site for intramuscular injections in adults due to its large, well-developed muscle mass and lower risk of hitting nerves or blood vessels. Using a 21-gauge needle (choice
A) is not specified for this particular injection and may not be appropriate for all medications. Inserting the needle at a 45° angle (choice
B) is not necessary for the vastus lateralis muscle and may not ensure proper depth of injection. Vigorously massaging the site (choice
D) can cause tissue damage and is not recommended post-injection.
Extract:
A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position.
Question 3 of 5
Which of the following questions should the nurse ask to evaluate the effectiveness of this intervention?
Correct Answer: C
Rationale: The correct answer is C: "Has your back labor improved?" This question is the most appropriate to evaluate the effectiveness of the intervention because it directly relates to the specific issue being addressed, which is back labor. By asking about improvement in back labor, the nurse can assess whether the intervention is targeting the problem effectively.
Choice A is incorrect because it focuses on pelvic pressure, which is not the main concern in this situation.
Choice B is incorrect as it pertains to contractions, not back labor.
Choice D is incorrect as it mentions suprapubic pain, which is not the primary focus of the intervention.
Choices E, F, and G are not provided, but they would also be incorrect if they do not target the issue of back labor.
Extract:
A nurse at an antepartum clinic is caring for four clients.
Question 4 of 5
Which of the following clients should the nurse assess first?
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client at 8 weeks gestation reporting severe vomiting first. This client could be suffering from hyperemesis gravidarum, a severe form of morning sickness that can lead to dehydration and electrolyte imbalances, posing a risk to both the mother and the fetus. Immediate assessment and intervention are crucial to prevent complications.
Choice A: Back pain following intercourse at 36 weeks gestation is common and usually not an urgent issue requiring immediate assessment.
Choice C: Frequent urination at 10 weeks gestation is a common symptom of early pregnancy and does not indicate an immediate need for assessment.
Choice D: Periodic tingling of the fingers at 24 weeks gestation could be due to carpal tunnel syndrome, which is common in pregnancy but does not require immediate assessment unless accompanied by other concerning symptoms.
Extract:
A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase intake of vitamin B.
Question 5 of 5
Which of the following foods should the nurse recommend?
Correct Answer: D
Rationale: The correct answer is D: Fortified soy milk. Soy milk is a good source of plant-based protein and fortified with essential nutrients like calcium and vitamin D, crucial for bone health. This is important for individuals who may have dietary restrictions or are lactose intolerant. Raw carrots (
A) are a good source of vitamins but may not provide enough protein. Brown rice (
B) is a healthy carbohydrate but lacks essential nutrients found in fortified soy milk. Fresh citrus fruits (
C) are rich in vitamin C but do not offer the same level of protein and nutrients as soy milk.