ATI RN
ATI RN Maternal Newborn 2023 II Questions
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 1 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 assessing a newborn who was born postterm.
Question 2 of 5
Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Nails extending over tips of fingers. This finding indicates clubbing, a condition associated with chronic hypoxia. Clubbing is characterized by the enlargement and flattening of the fingertips, causing the nails to extend over the fingertips. This can be seen in conditions such as chronic respiratory diseases or heart defects, where there is long-term oxygen deprivation. Large deposits of subcutaneous fat (
A) are not typically related to clubbing. Pale, translucent skin (
C) may suggest anemia or dehydration but is not directly related to clubbing. A thin covering of fine hair on shoulders and back (
D) is known as lanugo, which is commonly seen in newborns or individuals with eating disorders, and is not associated with clubbing.
Extract:
A nurse is assessing a newborn following a forceps-assisted birth.
Question 3 of 5
Which of the following clinical manifestations should the nurse identify as a complication of this birth method?
Correct Answer: A
Rationale: The correct answer is A: Facial palsy. Facial palsy can occur as a complication of birth trauma, particularly during a difficult delivery such as forceps or vacuum extraction. This can lead to injury of the facial nerve, resulting in weakness or paralysis of the facial muscles. Polycythemia (
B) is an increased number of red blood cells, not typically associated with birth method. Bronchopulmonary dysplasia (
C) is a lung condition primarily seen in premature infants requiring prolonged mechanical ventilation. Hypoglycemia (
D) is low blood sugar levels and can be caused by various factors unrelated to birth method.
Extract:
A nurse is caring for a newborn who has jaundice and a new prescription for phototherapy.
Question 4 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 5 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.