ATI RN
ATI RN Maternal Newborn 2023 II Questions
Extract:
A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique.
Question 1 of 5
Which of the following information should the nurse include?
Correct Answer: B
Rationale: The correct answer is B because it addresses a potentially serious issue that requires immediate attention - dark red discoloration at the tip of the baby's penis could indicate compromised blood flow and potential necrosis. This information is crucial for the parent to be aware of to prevent any complications.
The other choices are incorrect because:
A: Yellow exudate forming at the surgical site in 24 hours is normal post-circumcision and does not warrant immediate notification to the provider.
C: Ensuring a snug diaper fit is important for comfort and preventing leakage, but it is not as critical as identifying signs of compromised blood flow.
D: The Plastibell is typically removed after a few days, not 4 hours after the procedure. Providing this misinformation could cause unnecessary concern for the parent.
Extract:
A nurse is assessing a newborn whose mother had gestational diabetes mellitus.
Question 2 of 5
The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?
Correct Answer: B
Rationale: The correct answer is B: Jitteriness. Jitteriness is a common manifestation of hypoglycemia due to the brain not receiving enough glucose for energy. This can lead to shakiness, nervousness, and palpitations. Abdominal distention (choice
A) is not typically associated with hypoglycemia. Petechiae (choice
C) are tiny red or purple spots on the skin due to bleeding, not related to hypoglycemia. Increased muscle tone (choice
D) is not a common sign of hypoglycemia. By monitoring for jitteriness, the nurse can promptly recognize and address hypoglycemia in the patient.
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.
Question 4 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. Monitoring the client's serum medication level directly assesses medication adherence by measuring the actual concentration of the drug in the client's bloodstream. This objective measure provides concrete evidence of whether the client is taking the medication as prescribed. Asking the client (choice
A) may not always yield accurate information due to potential bias or forgetfulness. Determining the apical pulse rate (choice
B) is not directly related to medication adherence. Assessing kidney function (choice
D) is important but does not directly evaluate medication adherence.
Extract:
A nurse is assessing a client who is 3 days postpartum.
Question 5 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.