ATI RN
ATI Custom PNU Maternity Fall 2023 Questions
Extract:
A nurse is assisting with the care of a client who is using paced breathing during the first stage of labor. The client says she feels lightheaded and her fingers are tingling.
Question 1 of 5
Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct action for the nurse to take is A: Assist the client to breathe into a paper bag or cupped hand. This is appropriate for a client experiencing hyperventilation, as breathing into a paper bag helps rebreathe exhaled carbon dioxide, which can help normalize the client's breathing pattern. Option B is incorrect as it can exacerbate hyperventilation by increasing the respiratory rate further. Option C is incorrect as it is not a recommended intervention for hyperventilation. Option D is incorrect as administering oxygen may not address the underlying issue of hyperventilation.
Extract:
A nurse is assisting in the care of a client who is to undergo an amniotomy.
Question 2 of 5
Which of the following is the priority nursing action following this procedure?
Correct Answer: A
Rationale: The correct answer is A: Check the fetal heart rate pattern. This is the priority nursing action because it assesses the well-being of the fetus immediately after a procedure that may impact fetal distress. Monitoring the fetal heart rate helps identify any potential complications and guides further interventions. Evaluating for signs of infection (
B) is important but not the immediate priority post-procedure. Taking the client's temperature (
C) and observing amniotic fluid (
D) are important assessments but do not directly address fetal well-being.
Extract:
A nurse is reinforcing teaching about common discomforts of pregnancy during the first trimester with a client who is pregnant.
Question 3 of 5
Which of the following manifestations should the nurse include in the teaching?
Correct Answer: C
Rationale: The correct answer is C: Urinary urgency. This manifestation is relevant for a nurse to include in teaching as it can indicate potential urinary issues or infections. Heartburn (
A) and constipation (
B) are not typically associated with urinary problems. Supine hypotension (
D) is a condition where blood pressure drops when lying down, not related to urinary urgency.
Extract:
A nurse is assisting in the care of a newborn following birth. At 1 min after birth, the nurse notes: heart rate 110/min; slow, weak cry; some flexion of extremities; responds to suctioning of the nares with respiration of 20; body pink in color with blue extremities.
Question 4 of 5
What should the nurse document as the newborn's 1-min Apgar score?
Correct Answer: A
Rationale: The correct answer is A: 6. The Apgar score assesses the newborn's overall well-being at 1 and 5 minutes after birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each criterion is scored from 0 to 2, with a total score ranging from 0 to 10. A score of 6 at 1 minute indicates that the newborn may need some assistance or stimulation to establish breathing and circulation. Scores of 7-10 are considered normal, while scores below 7 may indicate the need for immediate medical attention.
Choices B, C, D, and E are incorrect as they represent higher Apgar scores indicating better overall well-being, which is not the case for a score of 6 at 1 minute.
Extract:
A nurse is preparing to examine a post-term newborn immediately following delivery.
Question 5 of 5
Which of the following findings should she expect to observe? (Select all that apply.)
Correct Answer: C,E
Rationale: The correct findings the nurse should expect to observe in a newborn are cracked, peeling skin (choice
C) and vernix in the folds and creases (choice E). Cracked, peeling skin is a normal postnatal adaptation due to the loss of the protective vernix caseosa. Vernix in the folds and creases is also expected as it helps protect the skin from the amniotic fluid. Moro reflex (choice
A) is a newborn reflex that involves the spreading out and then drawing in of the infant's arms in response to a sensation of falling, so this is not a expected finding. Heel to ear maneuverability (choice
B) is not a typical newborn assessment, so it is an incorrect choice. Abundant lanugo (choice
D) is fine hair that covers a newborn's body and is typically shed before birth, so it is an incorrect finding for a newborn.