ATI RN
ATI RN Maternal Newborn 2023 II Questions
Extract:
A nurse is caring for a client who has bladder distention following a vaginal birth.
Question 1 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.
Extract:
A nurse is caring for a client who is at 36 weeks of gestation and has methicillin-resistant Staphylococcus aureus.
Question 2 of 5
Which of the following types of isolation precautions should the nurse initiate?
Correct Answer: D
Rationale: The correct answer is D: Contact precautions. Contact precautions are necessary when a patient has an infection that spreads through direct or indirect contact. This includes wearing gloves, gowns, and proper hand hygiene. Droplet precautions (choice
A) are for infections spread through respiratory droplets, airborne precautions (choice
C) are for infections spread through airborne particles, and protective environment (choice
B) is for patients with compromised immune systems. The other choices are not relevant to the scenario described.
Extract:
A nurse is preparing to obtain a blood sample from a newborn's heel.
Question 3 of 5
In what order should the nurse perform the procedure?
Order the Items
Source Container
Correct Answer: A, B, C, D, E
Rationale: The correct order for the nurse to perform the procedure is A, B, C, D, E. First, applying a warm cloth to the newborn's heel for 5 to 10 min helps dilate the blood vessels for easier blood collection. Second, cleaning the area with an antiseptic prevents infection during the puncture. Third, puncturing the outer aspect of the newborn's heel allows for blood collection. Fourth, collecting the blood specimen is the main objective of the procedure. Finally, applying pressure to the site with a dry gauze pad helps stop bleeding and promotes healing.
Choices F and G are not provided in the question, so they are not applicable.
Extract:
A nurse is assessing a client who is 1 hr postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding.
Question 4 of 5
Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Massage the client's fundus. This is the first action the nurse should take after childbirth to prevent postpartum hemorrhage by ensuring the uterus contracts and expels clots. Providing oxygen (
A) is important but not the priority. Emptying the bladder (
B) can help prevent uterine atony, but massaging the fundus is more urgent. Administering oxytocin (
C) can also help prevent hemorrhage, but fundal massage is the initial step.
Extract:
A nurse is providing teaching to the guardians of a preterm newborn about temperature instability.
Question 5 of 5
Which of the following statements should the nurse make?
Correct Answer: A
Rationale: The correct statement is A because preterm newborns have less muscle tone, making them more susceptible to heat loss. This is due to their underdeveloped thermoregulatory mechanisms. Shivering (
B) is not a common response in newborns and is more likely to be seen in adults. Sweating (
C) is also not a common response in newborns as their sweat glands are not fully developed. Brown fat (
D) is essential for thermoregulation in newborns and helps them stay warm, not overheat.
Therefore, A is the correct statement as it directly addresses the vulnerability of preterm newborns to heat loss due to their low muscle tone.