ATI RN
ATI RN Maternal Newborn Latest Update. Questions
Extract:
A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hr old.
Physical Examination:
• Fontanels soft and flat
• Head molded with caput succedaneum
• Eyes symmetric, no discharge, sclera yellow
• Mucous membranes dry
• Abdomen soft and rounded, bowel sounds present x 4 quadrants
Question 1 of 5
Which of the following findings should the nurse report to the provider? (Select all that apply.)
Correct Answer: A,B,C,G
Rationale: The correct answers are A, B, C, and G. A Coombs test result is important for assessing for hemolytic anemia. Mucous membrane assessment is crucial for detecting dehydration or oxygenation issues. Intake and output are vital indicators of fluid balance. Sclera color can indicate liver function or jaundice.
Choices D, E, and F are not typically findings that would warrant immediate reporting to the provider unless they are significantly abnormal and impacting the patient's condition.
Extract:
A nurse is caring for a newborn.
Exhibit 1
Medical History
1600:
Apgar score 9 at 1 min and 9 at 5 min
Birth weight 4,706 g (10 lb 6 oz)
Gestational age 40 weeks
Difficult vaginal birth with shoulder dystocia. Exhibit 2
Nurses' Notes
1700:
Newborn is active and moves all extremities except for right arm. No spontaneous movement of
the right arm noted. Right arm remains at side during Moro reflex. Exhibit 3
Physical Examination
1830:
Absent Moro reflex noted in right arm.
Right shoulder and arm are internally rotated and adducted. Elbow extended. Forearm pronated
with wrist and fingers flexed. Diagnosis: Brachial plexus injury resulting in Erb-Duchenne (Erb's
palsy) paralysis.
Question 2 of 5
Which of the following actions should the nurse plan to implement? For each potential nursing action, click to specify if the intervention is indicated or contraindicated for the newborn.
Correct Answer:
Rationale:
Correct Answer: B: Assess for grasp reflex in the affected extremity.
Rationale: The correct action is to assess for the grasp reflex in the affected extremity. This is indicated to evaluate the newborn's neurological function and muscle strength. The grasp reflex is a normal developmental milestone that should be present in newborns. It helps assess the integrity of the nervous system and motor function in the affected arm.
Summary of Incorrect
Choices:
A: Educating parents to begin range of motion exercises after 1 week is contraindicated as it may cause further harm or injury to the affected arm without proper evaluation.
C: Immobilizing the arm across the abdomen is contraindicated as it may restrict blood flow and hinder proper movement and development of the arm.
D: Instructing parents to limit physical handling for 2 weeks is contraindicated as it may lead to muscle atrophy and delayed recovery.
Extract:
Question 3 of 5
A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B streptococcus ß-hemolytic (GBS). The client is multigravida and multipara with no history of GBS. She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the following is an appropriate response by the nurse?
Correct Answer: D
Rationale: The correct answer is D: We need to know if you are positive for GBS at the time of delivery. This is the appropriate response because GBS status can change during pregnancy, and it is crucial to know the status closer to delivery to determine if antibiotics are needed during labor to prevent transmission to the newborn.
Choice A is incorrect as GBS is often asymptomatic in pregnant women.
Choice B is incorrect because past negative results do not guarantee current negative status.
Choice C is incorrect because GBS status can change over time.
Question 4 of 5
A nurse in a provider’s office is caring for a 20-year-old client who is at 12 weeks of gestation and requests an amniocentesis to determine the sex of the fetus. Which of the following responses should the nurse make?
Correct Answer: B
Rationale: The correct response is B: This procedure determines if your baby has genetic or congenital disorders. At 12 weeks of gestation, amniocentesis is typically performed to detect genetic abnormalities, not to determine the sex of the fetus. This procedure involves collecting a sample of amniotic fluid to analyze the chromosomes for conditions like Down syndrome. Option A is incorrect as age is not a factor in determining the need for amniocentesis. Option C is incorrect because chorionic villus sampling is used for genetic testing, not determining the sex of the baby. Option D is incorrect because scheduling the procedure without addressing the client's request for sex determination is inappropriate.
Question 5 of 5
A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Provide the client with photos of the fetus. This action allows the client to create memories and acknowledge the loss, aiding in the grieving process. It also validates the existence of the stillborn and helps with closure.
A: Limiting the time the fetus is in the room may not address the emotional needs of the client.
C: Instructing the client about a mandatory autopsy may be insensitive and overwhelming during this emotional time.
D: Informing the client about a law requiring them to name the fetus is incorrect and may add unnecessary stress.