ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
A nurse is caring for a newborn who is 70 hr old. Exhibit 1
Medical History
Newborn delivered by repeat cesarean birth at 40 weeks of gestation.
Birth weight 3,515 g (7 lb 12 oz)
Apgar scores 8 at 1 min and 9 at 5 min
Maternal history of methadone use during pregnancy.
Exhibit 2
Vital Signs
0700:
Heart rate 156/min
Respiratory rate 58/min
Temperature 37.2° C (98.9° F)
Oxygen saturation 98% on room air
1100:
Heart rate 160/min
Respiratory rate 60/min
Temperature 37.3° C (99.2° F)
Oxygen saturation 96% on room air
Exhibit 3
Physical Examination
1100:
Newborn is inconsolable with a high-pitched cry. Newborn sucks vigorously on pacifier but
breastfeeds poorly. Respirations unlabored. Lungs sound clear on auscultation. Increased muscle
tone with moderate to severe tremors when disturbed. Hyperactive Moro reflex noted. Several
loose stools today.
Exhibit 4
Diagnostic Results
Maternal urine toxicology screen positive for opiates (negative)
Newborn urine toxicology screen positive for opiates (negative)
Question 1 of 5
Which of the following findings should the nurse report to the provider? Select all that apply.
Correct Answer: C,D
Rationale: The nurse should report central nervous system (CNS) and gastrointestinal (GI) findings to the provider as they may indicate significant health issues. CNS findings can suggest neurological problems, such as changes in mental status or weakness, requiring immediate attention. GI findings, like abdominal pain or bleeding, can indicate potential digestive system issues needing prompt evaluation. Reporting respiratory findings and oxygen saturation is important too but typically not as urgent as CNS and GI issues. It is essential to prioritize CNS and GI findings for timely intervention.
Extract:
Question 2 of 5
A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Determine respiratory function. The first priority in an unresponsive client is to assess their airway, breathing, and circulation (ABCs). Respiratory function is crucial for oxygenation and maintaining vital signs. If a client is unresponsive, assessing their respiratory status is essential to determine if they are breathing or in need of immediate intervention like CPR. Increasing IV fluid rate (
B) is not the priority as the client's respiratory status needs to be assessed first. Accessing emergency medications (
C) is not the immediate priority as the client's airway and breathing take precedence. Collecting a blood sample (
D) may be necessary later but is not the first action in an unresponsive client.
Question 3 of 5
A nurse is providing teaching about increasing dietary fiber to an antepartum client who reports constipation. Which of the following food selections has the highest fiber content per cup?
Correct Answer: D
Rationale: The correct answer is D: Lentils. Lentils have the highest fiber content per cup among the given options. One cup of cooked lentils contains about 15.6 grams of fiber, making it an excellent choice for increasing dietary fiber intake. Fiber helps prevent and alleviate constipation by promoting regular bowel movements. Oatmeal, cabbage, and asparagus also contain fiber, but in lower amounts compared to lentils. Oatmeal typically has around 4 grams of fiber per cup, while cabbage and asparagus have even lower fiber content.
Therefore, lentils are the best choice for the antepartum client aiming to increase fiber intake for constipation relief.
Question 4 of 5
A nurse is teaching about home safety with a client who is 2 days postpartum. Which of the following instructions should the nurse include in the teaching?
Correct Answer: D
Rationale: The correct answer is D: Wash your baby's face with plain water. This instruction is important for newborn care as it helps prevent skin irritation and infection. Washing with plain water is gentle and safe for the baby's delicate skin. Other choices are incorrect: A is incorrect because bathing immediately after a feeding can lead to discomfort and potential regurgitation. B is incorrect as bumper pads pose a suffocation hazard for infants. C is incorrect as a soft mattress increases the risk of sudden infant death syndrome.
Question 5 of 5
A nurse is caring for a newborn immediately following birth. For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?
Correct Answer: D
Rationale: The correct answer is D:
To facilitate bonding between the newborn and parent. Delaying the instillation of antibiotic ophthalmic ointment allows for uninterrupted skin-to-skin contact and bonding between the newborn and parent, which is crucial for establishing a strong emotional connection and promoting breastfeeding. This initial bonding period is a critical time for the newborn's emotional and psychological development.
Choices A, B, and C are incorrect because immediate instillation of the ointment is essential to prevent neonatal conjunctivitis, regardless of the newborn's weight, mode of delivery, or the need to identify infection manifestations.