ATI RN
ATI RN Maternal Newborn 2023 II Questions
Extract:
A nurse is assessing a client who is 3 days postpartum.
Question 1 of 5
Which of the following findings should the nurse report to the provider?
Correct Answer: C
Rationale: The correct answer is C: Cool, clammy skin. This finding indicates poor perfusion and potential hypoperfusion, which are critical conditions requiring immediate medical attention. Cool, clammy skin can be a sign of decreased blood flow and oxygen delivery to tissues. It suggests a possible decrease in cardiac output or circulation. Reporting this finding promptly to the healthcare provider is crucial for timely intervention to prevent further complications.
Choices A and B are within normal ranges for heart rate and blood pressure.
Choice D, moderate lochia serosa, is a normal postpartum finding as long as it is not excessive or accompanied by other concerning symptoms.
Extract:
A nurse is providing teaching to the guardians of a preterm newborn about temperature instability.
Question 2 of 5
Which of the following statements should the nurse make?
Correct Answer: A
Rationale: The correct statement is A because preterm newborns have less muscle tone, making them more susceptible to heat loss. This is due to their underdeveloped thermoregulatory mechanisms. Shivering (
B) is not a common response in newborns and is more likely to be seen in adults. Sweating (
C) is also not a common response in newborns as their sweat glands are not fully developed. Brown fat (
D) is essential for thermoregulation in newborns and helps them stay warm, not overheat.
Therefore, A is the correct statement as it directly addresses the vulnerability of preterm newborns to heat loss due to their low muscle tone.
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 planning care for a client who is 1 hr postpartum and has peripartum cardiomyopathy.
Question 4 of 5
Which of the following actions should the nurse plan to take?
Correct Answer: A
Rationale: The correct answer is A: Restrict daily oral fluid intake. This is the appropriate action for a patient with fluid overload, as it helps manage fluid balance. Restricting fluid intake can prevent further fluid accumulation and complications. Administering an IV bolus of lactated Ringer's (
B) would worsen fluid overload. Assessing blood pressure twice daily (
C) is important but not the priority in managing fluid overload. Obtaining a prescription for misoprostol (
D) is unrelated to managing fluid overload.
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: Check identification badges of staff who enter your room. This instruction is crucial for the safety and security of both the mother and newborn, ensuring only authorized personnel have access. Limiting visitors (
A) and removing monitoring bands (
C) can compromise safety. Sending the newborn to the nursery (
B) may hinder bonding and breastfeeding. The other choices are irrelevant as they do not address the security aspect.