ATI RN
ATI RN Maternal Newborn 2023 II Questions
Extract:
A nurse is caring for a newborn who has jaundice and a new prescription for phototherapy.
Question 1 of 5
Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct action is C: Close the newborn's eyes before applying eyepatches. This is important to prevent irritation and protect the newborn's eyes during the application of eyepatches. Closing the eyes reduces the risk of foreign particles entering the eyes. Providing glucose water (
A) is unnecessary and can lead to potential issues. Turning the newborn every 4 hours (
B) is a general care practice but not relevant to the specific scenario. Applying hydrating lotion (
D) before treatment is not necessary for applying eyepatches and may interfere with the adherence of the patches.
Extract:
A nurse is providing information about newborn security to the parents of a newborn.
Question 2 of 5
Which of the following instructions should the nurse provide?
Correct Answer: D
Rationale: The correct answer is D. Checking identification badges of staff who enter the room is crucial for ensuring the safety and security of the newborn and the mother. By verifying the identity of the staff, the nurse can prevent unauthorized individuals from accessing the room and potentially harming the newborn or the mother. This practice also helps in maintaining a secure and controlled environment within the healthcare setting.
Choice A is incorrect because limiting visitors to immediate family may not address all potential risks to the newborn and mother.
Choice B is incorrect as sending the newborn to the nursery while the mother is sleeping may disrupt bonding and breastfeeding.
Choice C is incorrect as removing the electronic monitoring band can compromise the monitoring of the newborn's vital signs.
Extract:
A nurse is administering a hepatitis B vaccine to a newborn.
Question 3 of 5
Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Administer the injection into the vastus lateralis muscle. This is the correct action because the vastus lateralis muscle is a common and safe site for intramuscular injections in adults. It has a relatively large muscle mass and is away from major nerves and blood vessels, reducing the risk of injury or complications. Massaging the site vigorously (choice
A) is not recommended as it can cause tissue damage and increase the risk of pain or bruising. Inserting the needle at a 45° angle (choice
B) is incorrect because the standard angle for intramuscular injections is 90°. Using a 21-gauge needle (choice
C) is not necessarily the best choice as needle gauge selection depends on factors such as patient age, body size, and medication viscosity.
Extract:
A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation.
Question 4 of 5
Which of the following findings should the nurse identify as a contraindication to the use of a suppository?
Correct Answer: C
Rationale:
Correct
Answer: C. Third-degree perineal laceration is a contraindication to the use of a suppository due to the risk of causing further trauma and infection. Suppositories are typically inserted rectally, and in the case of a third-degree perineal laceration, there is a significant risk of exacerbating the injury and delaying healing.
Incorrect
Choices:
A: Vaginal candidiasis - This is not a contraindication as suppositories can be used in the vagina for treating candidiasis.
B: Afterpains - Afterpains are not a contraindication for the use of a suppository.
D: Abdominal distention - Abdominal distention is not a direct contraindication to the use of a suppository unless it is due to a specific condition that may be worsened by the suppository.
Extract:
A nurse is caring for a newborn immediately following birth who has a prescription for erythromycin ophthalmic ointment. The guardian refuses the medication.
Question 5 of 5
Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Document the guardian's refusal of the medication. This is the appropriate action because it ensures accurate and complete documentation of the refusal, which is essential for legal and ethical reasons. Reporting to social services (
A) may not be necessary unless there are concerns for the child's safety. Informing the guardian about giving the medication after discharge (
C) may not be appropriate as immediate treatment may be necessary. Notifying the ethics committee (
D) is premature without documenting the refusal first.