ATI RN
ATI RN Maternal Newborn Updated 2023 Questions
Extract:
A client in the postpartum unit.
Question 1 of 5
Which of the following goals should the nurse identify for the client to accomplish during the taking-in phase of postpartum adjustment?
Correct Answer: D
Rationale: During the taking-in phase of postpartum adjustment, the focus is on the mother's own physical recovery and well-being.
Therefore, the most appropriate goal for the nurse to identify during this phase is D: The client will have adequate nutritional intake. This is crucial for the mother's own health and healing after childbirth. Proper nutrition supports her energy levels, helps with tissue repair, and aids in milk production if she chooses to breastfeed. The other choices are not as relevant during this phase. A and B are more related to infant care and safety, which are typically addressed in the later phases of postpartum adjustment. C involves family dynamics, which may be more pertinent in the later postpartum phases when the mother is more emotionally ready to focus on family roles.
Extract:
A client who is in labor and has received epidural analgesia.
Question 2 of 5
Which of the following findings should the nurse recognize and document as an adverse effect of epidural analgesia?
Correct Answer: A
Rationale: The correct answer is A: Hypotension. This is a known adverse effect of epidural analgesia due to sympathetic blockade leading to vasodilation. It can cause decreased blood pressure and compromise perfusion. Polyuria is not a typical effect of epidural analgesia. Fetal heart rate and maternal temperature are not directly related to the adverse effects of epidural analgesia.
Extract:
A newborn who is 2 hr old.
Question 3 of 5
Which of the following findings is an indication of hypoglycemia? (Select all that apply.)
Correct Answer: B,D,E
Rationale: The correct indications of hypoglycemia are jitteriness (
B), hypotonia (
D), and temperature instability (E). Jitteriness is a common sign of low blood sugar levels. Hypotonia refers to decreased muscle tone, often seen in infants with hypoglycemia. Temperature instability can occur due to the body's inability to regulate temperature when glucose levels are low. Abdominal distention (
A) and acrocyanosis (
C) are not typical signs of hypoglycemia and are more likely associated with other conditions.
Extract:
A client who is in labor and has a prescription for spinal anesthesia.
Question 4 of 5
Which of the following findings indicates that the IV bolus was effective?
Correct Answer: C
Rationale: The correct answer is C: Blood pressure 110/70 mm Hg. This finding indicates the IV bolus was effective because it signifies adequate perfusion and hemodynamic stability. A stable blood pressure within normal range suggests that the medication administered through the IV bolus is successfully supporting cardiac output and blood flow.
Choice A is incorrect as perineal pain is not necessarily a direct indicator of the effectiveness of the IV bolus.
Choice B, increased urinary output, could be a positive sign but does not directly confirm the effectiveness of the IV bolus in this situation.
Choice D, relief of pruritus, is also not a direct indicator of the IV bolus efficacy in this context.
Extract:
A newborn immediately following birth.
Question 5 of 5
How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or an indication that the client's condition is worsening.
| Finding | Unrelated to diagnosis | Indication client's condition is improving | Indication client's condition is worsening |
|---|---|---|---|
| Color: Consistent with genetic background - Unrelated | |||
| Axillary temperature 36.3° C (97.4°F), Reflex irritability: cry - Improving | |||
| Muscle tone: flaccid - Worsening | |||
| Respiration effort: good cry - Improving | |||
| Heart rate 140/min - Improving |
Correct Answer: A,B,C,D,E
Rationale:
The correct answer is A,B,C,D,E.
A: Color consistent with genetic background is unrelated to the diagnosis as it does not provide any direct information about the client's condition.
B: Axillary temperature 36.3°C, Reflex irritability: cry are indications that the client's condition is improving.
C: Muscle tone flaccid is an indication that the client's condition is worsening.
D: Respiration effort: good cry is an indication that the client's condition is improving.
E: Heart rate 140/min is an indication that the client's condition is improving.