ATI RN
ATI RN Maternal Newborn 2023 II Questions
Extract:
A nurse is assessing a newborn following a forceps-assisted birth.
Question 1 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 planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid.
Question 2 of 5
Which of the following actions should the nurse include in the plan of care?
Correct Answer: B
Rationale: The correct answer is B: Administer broad-spectrum antibiotics. This action is appropriate for preventing or treating infection at the site. Povidone-iodine cleansing (
A) may be too harsh for the wound. Surgical closure (
C) should be based on wound assessment, not a fixed time frame. Monitoring rectal temperature (
D) is not directly related to wound care. The nurse should focus on infection prevention and treatment, making administering antibiotics the most appropriate choice.
Extract:
A nurse is reviewing the prescriptions for a client who is pregnant and is taking digoxin.
Question 3 of 5
Which of the following actions should the nurse take to best evaluate the client's medication adherence?
Correct Answer: C
Rationale: The correct answer is C: Check the client's serum medication level. This action is the most direct and objective method to evaluate medication adherence. By measuring the actual concentration of the medication in the client's blood, the nurse can determine if the prescribed medication is being taken as directed. This method provides concrete evidence of adherence compared to just asking the client (
A), which may not always be reliable. Determining the apical pulse rate (
B) and assessing kidney function (
D) are important aspects of client care but are not directly related to evaluating medication adherence.
Extract:
A nurse is reviewing laboratory findings for a client who is at 20 weeks of gestation.
Question 4 of 5
Which of the following findings should the nurse report to the provider?
Correct Answer: B
Rationale: The correct answer is B: Fasting blood glucose 180 mg/dL (74 to 106 mg/dL). This finding indicates hyperglycemia, which can be a sign of diabetes or other underlying health issues requiring immediate attention. The nurse should report this to the provider for further evaluation and management to prevent complications.
A: WBC count 11,000/mm3 - Slightly elevated WBC count is common and may not warrant immediate reporting unless there are other concerning symptoms.
C: Hematocrit 37% - Falls within normal range and does not indicate any immediate issues.
D: Creatinine 0.9 mg/dL - Normal creatinine levels suggest healthy kidney function and do not require urgent reporting.
In summary, the nurse should report the high fasting blood glucose level as it signifies a potential health problem that needs prompt attention, while the other choices fall within normal ranges and do not require immediate reporting.
Extract:
A nurse at an antepartum clinic is caring for four clients.
Question 5 of 5
Which of the following clients should the nurse assess first?
Correct Answer: C
Rationale: The correct answer is C. The nurse should assess the client at 8 weeks of gestation reporting severe vomiting first as it may indicate hyperemesis gravidarum, a serious condition causing dehydration and electrolyte imbalances, risking maternal and fetal health. Severe vomiting can lead to complications like malnutrition and weight loss, affecting the developing fetus. Assessing this client first is crucial to provide immediate interventions and prevent further harm.
Other choices are less urgent: A - tingling fingers can be related to carpal tunnel syndrome common in pregnancy; B - back pain post-intercourse is common in late pregnancy due to pressure on the pelvis; D - frequent urination is a common early pregnancy symptom. These symptoms are not as concerning as severe vomiting, making choice C the priority.