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 providing prenatal teaching to a client who practices a vegan diet and is trying to increase intake of vitamin B.
Question 2 of 5
Which of the following foods should the nurse recommend?
Correct Answer: D
Rationale: The correct answer is D: Fortified soy milk. Soy milk is a good source of plant-based protein and fortified with essential nutrients like calcium and vitamin D, crucial for bone health. This is important for individuals who may have dietary restrictions or are lactose intolerant. Raw carrots (
A) are a good source of vitamins but may not provide enough protein. Brown rice (
B) is a healthy carbohydrate but lacks essential nutrients found in fortified soy milk. Fresh citrus fruits (
C) are rich in vitamin C but do not offer the same level of protein and nutrients as soy milk.
Extract:
A nurse is assessing a client who is 3 days postpartum.
Question 3 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.
Extract:
A nurse is collecting data from a client who is at 30 weeks of gestation.
Question 4 of 5
Which of the following findings should the nurse identify as a manifestation of pyelonephritis?
Correct Answer: B
Rationale: The correct answer is B: Flank pain. Pyelonephritis is an infection of the kidneys, causing inflammation and pain in the flank area. Flank pain is a common symptom due to the infection in the renal pelvis and kidney tissue. Epigastric discomfort (
A) is more indicative of gastrointestinal issues. Temperature elevation (
C) is a general sign of infection but not specific to pyelonephritis. Abdominal cramping (
D) is more associated with gastrointestinal problems.
Extract:
A nurse is assessing a newborn following a forceps-assisted birth.
Question 5 of 5
Which of the following clinical manifestations should the nurse identify as a complication of this birth method?
Correct Answer: B
Rationale: The correct answer is B: Facial palsy. This birth method refers to a forceps delivery, which can cause nerve damage leading to facial palsy. Forceps application during delivery can put pressure on the baby's facial nerves, resulting in temporary or permanent facial paralysis. Polycythemia (
A) is not typically associated with forceps delivery. Bronchopulmonary dysplasia (
C) is a lung condition in premature babies, not directly related to forceps delivery. Hypoglycemia (
D) can occur in newborns due to various reasons, but it is not a specific complication of forceps delivery.