ATI RN
ATI RN Maternal Newborn 2023 Questions
Extract:
A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum.
Question 1 of 5
Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct action is to provide the client with a cool sitz bath (
Choice
C). This helps reduce perineal swelling and discomfort postpartum. Administering methylergonovine (
Choice
A) is used to manage postpartum hemorrhage. Applying povidone-iodine (
Choice
B) can cause skin irritation. Applying a warm compress (
Choice
D) may increase perineal swelling.
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 term newborn who is 48 hr old. Physical Examination: High-pitched cry, Mild tremors when disturbed, Increased muscle tone, Sneezing six times within 1 hr, Excessive sucking, Color: Consistent with genetic background, Excoriation of the chin, Watery stools, Projectile vomiting, Hyperactive Moro reflex.
Question 3 of 5
The nurse is assessing the newborn 24 hr later. How should the nurse interpret the findings? (Select one representative finding)
Correct Answer: D
Rationale: The correct answer is D: Continuous high-pitched cry. This finding indicates potential issues like discomfort, hunger, or illness in the newborn. It's concerning because continuous crying can be a sign of distress or underlying medical problems. Regurgitation (
A) is common in newborns due to immature digestive system. Mottling (
B) is a transient skin discoloration that can occur normally in newborns. Transient strabismus (
C) is common as newborns' eye muscles are still developing. Respiratory rate of 70/min (E) is within the normal range for newborns. Loose stools (F) are expected in breastfed newborns.
Extract:
A nurse is planning care for a client who is 1 hr postpartum and has peripartum cardiomyopathy.
Question 4 of 5
Which of the following actions should the nurse plan to take?
Correct Answer: D
Rationale: The correct answer is D: Restrict daily oral fluid intake. This action is important for patients with heart failure to prevent fluid overload. Administering an IV bolus of lactated Ringer's (
A) can exacerbate fluid overload. Obtaining misoprostol (
B) is not relevant to managing heart failure. Assessing blood pressure twice daily (
C) is important but not the priority.
Extract:
A nurse is caring for a newborn who is 5 days old. Medical History: History of maternal opioid use prior to pregnancy and prescribed methadone use during pregnancy. Maternal and neonatal positive urine drug screens for methadone. Newborn is exhibiting clinical findings of neonatal abstinence syndrome (NAS).
Question 5 of 5
Which of the following actions should the nurse take? Select all that apply.
Correct Answer: A, F, G
Rationale: The correct actions for the nurse to take are A, F, and G.
- A: Maintaining a low stimulation environment is important for newborns to promote rest and decrease stress.
- F: Weighing the newborn daily helps monitor their growth and detect any potential issues early.
- G: Swaddling the newborn with flexed extremities can provide comfort and mimic the womb environment, helping to soothe the baby.
Other choices are incorrect:
- B: Naloxone is not routinely administered to newborns unless specific circumstances warrant it.
- C: Breastfeeding is typically encouraged unless contraindicated by specific circumstances.
- D: Eye contact during feeding is important for bonding and communication between the parent and newborn.
- E: Performing Ballard newborn screening each shift is not necessary and may cause unnecessary stress to the newborn.