ATI RN
ATI RN Maternal Newborn Latest Update. Questions
Extract:
A nurse is caring for a newborn.
Exhibit 1
Medical History
1600:
Apgar score 9 at 1 min and 9 at 5 min
Birth weight 4,706 g (10 lb 6 oz)
Gestational age 40 weeks
Difficult vaginal birth with shoulder dystocia. Exhibit 2
Nurses' Notes
1700:
Newborn is active and moves all extremities except for right arm. No spontaneous movement of
the right arm noted. Right arm remains at side during Moro reflex. Exhibit 3
Physical Examination
1830:
Absent Moro reflex noted in right arm.
Right shoulder and arm are internally rotated and adducted. Elbow extended. Forearm pronated
with wrist and fingers flexed. Diagnosis: Brachial plexus injury resulting in Erb-Duchenne (Erb's
palsy) paralysis.
Question 1 of 5
Which of the following actions should the nurse plan to implement? For each potential nursing action, click to specify if the intervention is indicated or contraindicated for the newborn.
Correct Answer:
Rationale:
Correct Answer: B: Assess for grasp reflex in the affected extremity.
Rationale: The correct action is to assess for the grasp reflex in the affected extremity. This is indicated to evaluate the newborn's neurological function and muscle strength. The grasp reflex is a normal developmental milestone that should be present in newborns. It helps assess the integrity of the nervous system and motor function in the affected arm.
Summary of Incorrect
Choices:
A: Educating parents to begin range of motion exercises after 1 week is contraindicated as it may cause further harm or injury to the affected arm without proper evaluation.
C: Immobilizing the arm across the abdomen is contraindicated as it may restrict blood flow and hinder proper movement and development of the arm.
D: Instructing parents to limit physical handling for 2 weeks is contraindicated as it may lead to muscle atrophy and delayed recovery.
Extract:
A nurse is caring for a client who is at 33 weeks of gestation.
Diagnostic Results:
• Proteinuria 3+, straw-colored urine
• Platelet count 150,000/mm3 (150,000 to 400,000/mm3)
• BUN 18 mg/dL (10 to 20 mg/dL)
Question 2 of 5
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
| Findings 24 hr later | Sign of potential worsening condition | Sign of potential improvement | Unrelated to diagnosis |
|---|---|---|---|
| Hematuria | |||
| Proteinuria 2+ | |||
| Leukorrhea | |||
| Positive clonus | |||
| BUN 40 mg/dL | |||
| Platelet count 110,000/mm3 |
Correct Answer:
Rationale:
Correct Answer:
Rationale: The nurse should interpret Proteinuria 2+ as a sign of a potential worsening condition due to kidney damage. Hematuria could indicate a urinary tract issue but is less specific than proteinuria for this client. Leukorrhea is unrelated to the diagnosis. Positive clonus is typically associated with neurological issues, not related to kidney function. BUN and platelet count are not provided in the table, so they should not be considered in the interpretation.
Extract:
Question 3 of 5
A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?
Correct Answer: A
Rationale:
Correct Answer: A - Apply a moist, warm compress to the perineum.
Rationale: Applying a moist, warm compress helps to reduce swelling and promote healing in the perineal area. This can provide comfort and pain relief for the client with a fourth-degree laceration. It also helps to increase blood flow to the area, aiding in the healing process.
Summary of other choices:
B: Providing a cool sitz bath may not be appropriate for a fourth-degree laceration as warmth is usually more soothing and beneficial.
C: Administering methylergonovine may be contraindicated as it can cause uterine contractions and increase the risk of bleeding in a client with a fourth-degree laceration.
D: Applying povidone-iodine may be too harsh for the delicate perineal area and can potentially cause irritation or delay healing.
Question 4 of 5
A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Assist the client in pulling their knees toward their abdomen. The McRoberts maneuver is used to alleviate shoulder dystocia by hyperflexing the mother's legs on her abdomen. This action widens the pelvic outlet and helps to dislodge the baby's shoulder. Applying pressure to the fundus (
A) would not be effective in resolving shoulder dystocia. Pressing on the suprapubic area (
B) does not directly address the issue of shoulder dystocia. Moving the client onto their hands and knees (
C) does not assist in resolving the shoulder dystocia.
Therefore, assisting the client in pulling their knees toward their abdomen (
D) is the correct action.
Question 5 of 5
A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?
Correct Answer: A
Rationale:
Correct Answer: A
Rationale: It is important for the nurse to instruct the client to have her provider refit her for a new diaphragm because postpartum changes in the body, such as weight loss or gain, can affect the fit of the diaphragm. A properly fitting diaphragm is essential for effective contraception.
Summary:
B: Using oil-based vaginal lubricant can weaken the diaphragm and increase the risk of contraceptive failure.
C: Keeping the diaphragm in place for an extended period after intercourse does not provide additional contraceptive benefits.
D: Storing the diaphragm in sterile water is not necessary and can actually damage the diaphragm.