ATI RN
ATI RN Maternal Newborn 2023 II Questions
Extract:
A nurse is assessing a newborn who was born 2 hr ago and was admitted to the neonatal intensive care unit with chest wall retractions and blue discoloration of the hands and feet.
Question 1 of 5
Which of the following findings indicates a decline in the newborn's status?
Correct Answer: D
Rationale: The correct answer is D: Oxygen saturation of 89%. A low oxygen saturation level indicates poor oxygenation, which is a critical indicator of a decline in the newborn's status. Oxygen saturation below 90% is concerning and may lead to hypoxia, affecting vital functions. Nasal flaring (
A) and fine crackles (
C) can be early signs of respiratory distress but do not directly indicate a decline. An apneic episode less than 15 seconds (
B) is common in newborns and does not necessarily indicate a significant decline. In summary, a low oxygen saturation level is the most critical finding that indicates a decline in the newborn's status compared to the other choices.
Extract:
A nurse is teaching about car seat safety to the parents of a newborn who was delivered at 38 weeks of gestation.
Question 2 of 5
Which of the following statements by a parent indicates an understanding of the teaching?
Correct Answer: D
Rationale: The correct answer is D because positioning the car seat at a 45-degree angle is crucial for the safety of the baby. This angle helps prevent the baby's head from falling forward and restricting their airway.
Choices A, B, and C are incorrect because a car seat challenge test is not related to understanding teaching, using a sleep sack in a car seat may compromise safety, and turning the car seat forward before the recommended age is unsafe.
Extract:
A nurse is assessing a client who is at 6 weeks of gestation and adheres to a vegan diet.
Question 3 of 5
Which of the following questions should the nurse ask to assess the client's dietary intake?
Correct Answer: B
Rationale: The correct answer is B: "How much protein do you eat in a day?" This question is important as it directly assesses the client's dietary intake related to protein, a crucial component of a balanced diet. By asking about the amount of protein consumed, the nurse can evaluate the client's protein intake and identify any deficiencies or excesses. This information is essential for assessing the client's overall nutritional status.
Choices A, C, and D do not directly assess the client's dietary intake but focus on specific food items or supplements. These questions may provide valuable information but do not address the broader dietary intake.
Therefore, they are incorrect in this context.
Extract:
A nurse is administering a hepatitis B vaccine to a newborn.
Question 4 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 caring for a client who has bladder distention following a vaginal birth.
Question 5 of 5
Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Escort the client to the bathroom. This action should be taken first to address the immediate need of the client for toileting. It promotes the client's comfort, maintains their dignity, and prevents potential complications like urinary retention. Option B (Offer the client a sitz bath) and C (Pour warm water over the client's perineum) are not priorities as they do not address the client's urgent need for toileting. Option D (Insert a urinary catheter) is an invasive procedure and should not be the first action unless indicated for a specific medical reason. Options E and F (None) are not appropriate as there is a clear immediate need that requires action.