ATI RN
ATI RN Maternal Newborn 2023 II Questions
Extract:
A nurse is reviewing the prescriptions for a client who is pregnant and is taking digoxin.
Question 1 of 5
Which of the following actions should the nurse take to best evaluate the client's medication adherence?
Correct Answer: C
Rationale: The correct answer is C: Check the client's serum medication level. Monitoring the client's serum medication level directly assesses medication adherence by measuring the actual concentration of the drug in the client's bloodstream. This objective measure provides concrete evidence of whether the client is taking the medication as prescribed. Asking the client (choice
A) may not always yield accurate information due to potential bias or forgetfulness. Determining the apical pulse rate (choice
B) is not directly related to medication adherence. Assessing kidney function (choice
D) is important but does not directly evaluate medication adherence.
Extract:
A nurse is assessing a newborn who was born postterm.
Question 2 of 5
Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Nails extending over tips of fingers. This finding indicates clubbing, a condition associated with chronic hypoxia. Clubbing is characterized by the enlargement and flattening of the fingertips, causing the nails to extend over the fingertips. This can be seen in conditions such as chronic respiratory diseases or heart defects, where there is long-term oxygen deprivation. Large deposits of subcutaneous fat (
A) are not typically related to clubbing. Pale, translucent skin (
C) may suggest anemia or dehydration but is not directly related to clubbing. A thin covering of fine hair on shoulders and back (
D) is known as lanugo, which is commonly seen in newborns or individuals with eating disorders, and is not associated with clubbing.
Extract:
A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception.
Question 3 of 5
Which of the following instructions should the nurse include?
Correct Answer: A
Rationale: The correct answer is A: "You should have your provider refit you for a new diaphragm." This is correct because diaphragms should be refitted periodically to ensure proper fit and effectiveness.
Choice B is incorrect because diaphragms should be left in place for at least 6 hours after intercourse, not 4.
Choice C is incorrect as oil-based lubricants can degrade the diaphragm material, so water-based lubricants should be used.
Choice D is incorrect because diaphragms should be stored dry, not in sterile water.
Extract:
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid.
Question 4 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 delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage.
Question 5 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.