ATI RN Maternal Newborn Updated 2023

Extract:

A client who is at 35 weeks of gestation.

Question 1 of 5

Which of the following findings should indicate to the nurse the need for further diagnostic testing?

A. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period B. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period C. Three fetal movements perceived by the client in a 20-min testing period D. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client

Correct Answer: C

Rationale: The correct answer is C. The reason further testing is needed when there are three fetal movements perceived by the client in a 20-minute period is that fetal movement assessment is crucial for assessing fetal well-being. A decrease or absence of fetal movements can indicate fetal distress, prompting the need for further evaluation to ensure the well-being of the fetus. In contrast, options A, B, and D describe normal or reassuring findings within the parameters of fetal heart rate monitoring and contractions, indicating fetal well-being. Option A shows a reassuring acceleration in fetal heart rate, option B indicates absence of late decelerations, and option D describes contractions that are not concerning if not felt by the client.

Extract:

A client who reports methadone use during pregnancy.

Question 2 of 5

The nurse should expect the newborn to exhibit which of the following manifestations?

A. Poor feeding B. Weak cry C. Absent Moro reflex D. Respiratory rate of 30/min

Correct Answer: A

Rationale: The correct answer is A: Poor feeding. Newborns may exhibit poor feeding due to various reasons such as immature sucking reflex, inadequate milk production, or other health issues. This is a common manifestation that nurses should expect and address promptly to ensure the newborn's well-being. Weak cry (
B) and absent Moro reflex (
C) are concerning signs that may indicate neurological or developmental issues, but they are not typical manifestations expected in all newborns. Respiratory rate of 30/min (
D) is within the normal range for newborns, so it is not a significant concern unless accompanied by other respiratory distress symptoms.

Extract:

A newborn who has a myelomeningocele that is leaking cerebrospinal fluid.

Question 3 of 5

Which of the following actions should the nurse include in the plan of care?

A. Prepare for surgical closure after 72 hr B. Monitor the rectal temperature every 4 hr C. Cleanse the site with povidone-iodine D. Administer broad-spectrum antibiotics

Correct Answer: D

Rationale: The correct answer is D: Administer broad-spectrum antibiotics. This is crucial in the plan of care to address potential infection post-injury. Antibiotics help prevent or treat infections that can develop in the wound site. Monitoring rectal temperature (
B) does not directly address wound care. Preparing for surgical closure (
A) can be important but addressing infection is a higher priority. Cleansing with povidone-iodine (
C) is a good practice, but antibiotics are necessary for systemic infection prevention.

Extract:

A client who is 6 hr postpartum and is saturating perineal pads every 10 to 15 min.

Question 4 of 5

Which of the following actions should the nurse take first?

A. Collect hemoglobin and hematocrit levels B. Insert an indwelling urinary catheter C. Administer oxygen via face mask at 10 L/min D. Prepare the client to receive a plasma expander

Correct Answer: A

Rationale: The correct answer is A: Collect hemoglobin and hematocrit levels. This is the first action the nurse should take to assess the client's oxygen-carrying capacity and hydration status. It provides crucial data for determining the client's overall health status. Inserting an indwelling urinary catheter (
B) is not the priority unless indicated. Administering oxygen via face mask (
C) is important, but assessing the client's hemoglobin and hematocrit levels takes precedence. Preparing the client to receive a plasma expander (
D) should only be done after assessing the client's current status.

Extract:

A client who is in labor and has a spontaneous rupture of membranes. The nurse notes that the umbilical cord is protruding from the client's vagina.

Question 5 of 5

After calling for help, which of the following actions should the nurse take first?

A. Use fingers to exert upward pressure on the presenting part B. Administer a tocolytic medication C. Apply oxygen via facemask to the client D. Wrap the cord in a sterile towel and moisten with warm sterile normal saline

Correct Answer: A

Rationale: The correct action is A: Use fingers to exert upward pressure on the presenting part. This is the first step in managing a prolapsed cord to alleviate pressure on the cord and prevent fetal hypoxia. Immediate action is crucial in this emergency situation. Administering tocolytic medication (
B) is not the priority as it does not address the immediate risk to the fetus. Applying oxygen via facemask (
C) is important but secondary to relieving cord compression. Wrapping the cord in a sterile towel (
D) is not recommended as it can further compress the cord.

ATI RN Maternal Newborn Updated 2023 | Nurselytic

Nurselytic

ATI RN

ATI RN