ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
A nurse is caring for a client who is pregnant in an antepartum clinic.
Vital Signs
0900:
Temperature 36.6°C (97.9°F)
Heart rate 88/min
Respiratory rate 18/min
Blood pressure 130/70 mm Hg
Oxygen saturation 97% on room air
1000:
Heart rate 76/min
Respiratory rate 20/min
Blood pressure 138/68 mm Hg
Oxygen saturation 98% on room air
Question 1 of 5
Which of the following findings should the nurse report to the provider?Select the 3 findings that should be reported.
Correct Answer: A,B,D
Rationale: The nurse should report uterine contractions (
A) as they can indicate preterm labor. Fetal heart rate (
B) should be reported to monitor fetal well-being. Vaginal examination (
D) findings are important to assess cervical changes. Gestational age (
C) and maternal blood pressure (E) are routine assessments and do not necessarily require immediate reporting.
Extract:
Question 2 of 5
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?
Correct Answer: A
Rationale: The correct answer is A: Administer broad-spectrum antibiotics. This is crucial to prevent infection in the exposed neural tissue. Myelomeningocele increases the risk of meningitis due to the breach in the protective layers of the spinal cord. Administering antibiotics helps to prevent bacterial invasion and subsequent infection. Monitoring rectal temperature is not directly related to the myelomeningocele issue. Cleaning the site with povidone-iodine may cause further irritation to the exposed tissue. Immediate surgical closure is usually necessary to prevent infection; waiting 72 hours is not appropriate in this case.
Question 3 of 5
A nurse is caring for a client who is 1 hr postpartum and has uterine atony. The client is exhibiting a large amount of vaginal bleeding. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Anticipate a prescription for misoprostol. Misoprostol is a medication used to help control postpartum hemorrhage by promoting uterine contractions which can help stop the bleeding due to uterine atony. It is important to address the underlying cause of the bleeding to prevent further complications.
Choice A: Administering betamethasone IM is not appropriate in this situation as it is a corticosteroid used to promote fetal lung development in preterm labor, not for controlling postpartum hemorrhage.
Choice B: Avoiding performing sterile vaginal examinations is not helpful in managing postpartum hemorrhage. Vaginal examinations may be necessary to assess the degree of bleeding and uterine tone.
Choice D: Obtaining a specimen for a Kleihauer-Betke test is used to determine the amount of fetal-maternal hemorrhage in cases of Rh incompatibility, not for immediate management of postpart
Question 4 of 5
A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?
Correct Answer: A
Rationale: The correct answer is A: Oligohydramnios. Electronic fetal monitoring is used to assess the well-being of the fetus during pregnancy. Oligohydramnios, which is a low level of amniotic fluid, can indicate poor fetal perfusion and compromise, necessitating closer monitoring. Hyperemesis gravidarum (
B) is severe morning sickness and does not directly affect fetal well-being. Leukorrhea (
C) is normal vaginal discharge during pregnancy and does not require fetal monitoring. Periodic tingling of the fingers (
D) is unrelated to fetal assessment.
Question 5 of 5
A nurse is admitting a client to the birthing unit who reports her contractions started 1 hr ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions?
Correct Answer: D
Rationale: The correct answer is D: Postpartum hemorrhage. The client being 80% effaced and 8 cm dilated indicates she is in active labor, not pregnant with an ectopic pregnancy. Hyperemesis gravidarum is severe nausea and vomiting during pregnancy, which is not related to the client's current condition. Incompetent cervix would present earlier in pregnancy with painless cervical dilation, not during active labor. Postpartum hemorrhage is a risk due to the advanced dilation and effacement, making the uterus more prone to atony and excessive bleeding after delivery.