ATI RN
ATI RN Maternal Newborn 2023 II Questions
Extract:
A nurse is planning care for a client who is 1 hr postpartum and has peripartum cardiomyopathy.
Question 1 of 5
Which of the following actions should the nurse plan to take?
Correct Answer: A
Rationale: The correct answer is A: Restrict daily oral fluid intake. This is the appropriate action for a patient with fluid overload, as it helps manage fluid balance. Restricting fluid intake can prevent further fluid accumulation and complications. Administering an IV bolus of lactated Ringer's (
B) would worsen fluid overload. Assessing blood pressure twice daily (
C) is important but not the priority in managing fluid overload. Obtaining a prescription for misoprostol (
D) is unrelated to managing fluid overload.
Extract:
A nurse is assessing a newborn who was born 2 hr ago and was admitted to the neonatal intensive care unit with chest wall retractions and blue discoloration of the hands and feet.
Question 2 of 5
Which of the following findings indicates a decline in the newborn's status?
Correct Answer: D
Rationale: The correct answer is D: Oxygen saturation of 89%. A low oxygen saturation level indicates poor oxygenation, which is a critical indicator of a decline in the newborn's status. Oxygen saturation below 90% is concerning and may lead to hypoxia, affecting vital functions. Nasal flaring (
A) and fine crackles (
C) can be early signs of respiratory distress but do not directly indicate a decline. An apneic episode less than 15 seconds (
B) is common in newborns and does not necessarily indicate a significant decline. In summary, a low oxygen saturation level is the most critical finding that indicates a decline in the newborn's status compared to the other choices.
Extract:
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid.
Question 3 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 caring for a client who is receiving an epidural block with an opioid analgesic.
Question 4 of 5
The nurse should monitor for which of the following findings as an adverse effect of the medication?
Correct Answer: B
Rationale: The correct answer is B: Hypotension. Hypotension is a common adverse effect of many medications, especially those that affect blood pressure or circulation. The nurse should monitor for signs such as dizziness, lightheadedness, or low blood pressure readings. Polyuria (
A) is excessive urination, not typically an adverse effect of medications. Bilateral crackles (
C) indicate fluid in the lungs, not a common adverse effect of medications. Hyperglycemia (
D) is high blood sugar, often seen with certain medications like steroids or glucose-lowering drugs.
Extract:
A nurse is caring for a client who has bladder distention following a vaginal birth.
Question 5 of 5
Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Assist the client to the bathroom. This is the first action the nurse should take because it addresses the most immediate need of the client, which is to relieve themselves. It ensures the client's comfort and promotes their dignity. Option B, offering a sitz bath, can be considered later for comfort but does not address the urgent need. Option C, pouring warm water over the client's perineum, may provide relief but does not address the primary need. Option D, inserting a urinary catheter, is an invasive procedure and should only be considered after other non-invasive interventions have been attempted.