ATI RN
ATI RN Maternal Newborn 2023 Questions
Extract:
A nurse is administering a hepatitis B vaccine to a newborn.
Question 1 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 client who is 1 day postpartum and breastfeeding her newborn. The client reports sore nipples.
Question 2 of 5
Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Assess the newborn's latch while breastfeeding. This action is crucial as a proper latch is essential for effective breastfeeding, ensuring the baby receives enough milk and prevents nipple soreness. By assessing the latch, the nurse can identify and correct any issues early on, promoting successful breastfeeding.
A: Limiting breastfeeding time may hinder milk production and not address the root cause of latch issues.
B: Waiting 4 hours between feedings can lead to insufficient milk intake for the baby.
C: Offering supplemental formula can interfere with breastfeeding and reduce milk supply.
E, F, G: Irrelevant options.
Extract:
A nurse is providing discharge teaching to a client following tubal ligation.
Question 3 of 5
Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: D
Rationale: The correct answer is D because it shows an understanding of the teaching about the procedure not affecting ovulation. A: Incorrect, as the length of the menstrual period was not discussed. B: Incorrect, as premenstrual tension was not mentioned to change. C: Incorrect, as hormone replacements were not mentioned.
Extract:
A nurse is teaching about home safety with a client who is 2 days postpartum.
Question 4 of 5
Which of the following instructions should the nurse include in the teaching?
Correct Answer: C
Rationale: The correct answer is C: Wash your baby's face with plain water. This instruction is important for maintaining good hygiene and preventing skin irritation. Washing with plain water is gentle and safe for a baby's delicate skin.
Choice A is incorrect as bathing immediately after feeding can lead to discomfort and potential choking hazards.
Choice B is incorrect as soft mattresses can increase the risk of Sudden Infant Death Syndrome (SIDS).
Choice D is incorrect as bumper pads pose a suffocation risk for infants.
Extract:
A nurse is assessing a client who is 3 days postpartum.
Question 5 of 5
Which of the following findings should the nurse report to the provider?
Correct Answer: B
Rationale: The correct answer is B: Cool clammy skin. This finding may indicate poor perfusion or shock, which could be concerning postpartum. The nurse should report this to the provider promptly for further evaluation and intervention.
A: BP 120/70 mm Hg is within normal range for postpartum, so it does not require immediate reporting.
C: Moderate lochia serosa is expected in the early postpartum period, so it is not a concerning finding that requires immediate reporting.
D: Heart rate of 89/min is slightly elevated but not critically high, so it does not necessitate immediate reporting.
In summary, the other choices are not as urgent or abnormal as cool clammy skin, which may indicate a more serious issue requiring prompt attention.