ATI RN
ATI RN Maternal Newborn 2023 II 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: B
Rationale: The correct answer is B: Administer broad-spectrum antibiotics. This action is appropriate for preventing or treating infection at the site. Povidone-iodine cleansing (
A) may be too harsh for the wound. Surgical closure (
C) should be based on wound assessment, not a fixed time frame. Monitoring rectal temperature (
D) is not directly related to wound care. The nurse should focus on infection prevention and treatment, making administering antibiotics the most appropriate choice.
Extract:
A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique.
Question 2 of 5
Which of the following information should the nurse include?
Correct Answer: B
Rationale: The correct answer is B because it addresses a potentially serious issue that requires immediate attention - dark red discoloration at the tip of the baby's penis could indicate compromised blood flow and potential necrosis. This information is crucial for the parent to be aware of to prevent any complications.
The other choices are incorrect because:
A: Yellow exudate forming at the surgical site in 24 hours is normal post-circumcision and does not warrant immediate notification to the provider.
C: Ensuring a snug diaper fit is important for comfort and preventing leakage, but it is not as critical as identifying signs of compromised blood flow.
D: The Plastibell is typically removed after a few days, not 4 hours after the procedure. Providing this misinformation could cause unnecessary concern for the parent.
Extract:
A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr. ago.
Question 3 of 5
Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply.)
Correct Answer: C, D, E
Rationale:
Correct Answer: C, D, E
Rationale:
C: Labor induction with oxytocin increases the risk of postpartum hemorrhage due to uterine hyperstimulation leading to poor uterine muscle contractions.
D: History of uterine atony indicates weak uterine muscles, which can result in ineffective contraction post-delivery, leading to hemorrhage.
E: Vacuum-assisted delivery can cause trauma to the birth canal and uterus, increasing the risk of postpartum hemorrhage.
Summary of Incorrect
Choices:
A: Newborn weight is not a direct risk factor for postpartum hemorrhage.
B: History of human papillomavirus does not predispose to postpartum hemorrhage.
F, G: No information provided.
Extract:
A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage.
Question 4 of 5
Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct action for the nurse to take is option C: Evaluate urinary output. This is crucial post-surgery to assess renal function and fluid status, ensuring proper kidney function and hydration. Monitoring urinary output helps detect early signs of complications like acute kidney injury or fluid imbalance. Applying an ice pack (
A) may be indicated for pain management, but it does not address the immediate concern of renal function. Administering IV fluids (
B) without assessing the need based on urinary output can lead to fluid overload or dehydration. While replacing the surgical dressing (
D) is important for wound care, it is not the priority in this scenario.
Extract:
A nurse is caring for a newborn immediately following birth.
Question 5 of 5
For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?
Correct Answer: B
Rationale: The correct answer is B:
To facilitate bonding between the newborn and parent. Delaying the instillation of antibiotic ointment allows for crucial bonding time between the newborn and parent, promoting emotional connection and attachment. This early bonding is essential for the newborn's overall well-being and development.
Choice A is incorrect because the newborn's weight does not impact the timing of antibiotic ointment instillation.
Choice C is incorrect as delaying the ointment does not help in identifying infection manifestations.
Choice D is incorrect as the mode of delivery does not affect the timing of antibiotic ointment instillation.