ATI RN
ATI RN Maternal Newborn Updated 2023 Questions
Extract:
A client who is postpartum and just delivered a newborn who weighs 4.5 kg (10 lb).
Question 1 of 5
Which of the following manifestations should the nurse recognize as a potential sign of hemorrhage?
Correct Answer: A
Rationale: The correct answer is A. A blood pressure of 88/40 mm Hg is indicative of hypotension, which is a common sign of hemorrhage due to decreased blood volume. Hypotension results from the body's compensatory mechanisms to maintain perfusion. Options B, C, and D are not specific indicators of hemorrhage. Urinary output of 40 mL/hr is within normal range, moderate rubra lochia is expected in the postpartum period, and a heart rate of 90/min is not necessarily abnormal. It is crucial for the nurse to recognize hypotension as a potential sign of hemorrhage to intervene promptly and prevent further complications.
Extract:
A client who is in labor.
Question 2 of 5
Which of the following findings should prompt the nurse to reassess the client?
Correct Answer: B
Rationale: The correct answer is B. An urge to have a bowel movement during contractions should prompt the nurse to reassess the client because it could indicate the need to push, which could lead to premature delivery. This finding can signal the need for further evaluation to prevent complications. Intense contractions lasting 45 to 60 seconds (
A) are normal during labor. A sense of excitement and warm, flushed skin (
C) can be a normal response to the labor process. Progressive sacral discomfort during contractions (
D) is common due to pressure on the sacrum during labor.
Extract:
Parents of a newborn about the Plastibell circumcision technique.
Question 3 of 5
Which of the following information should the nurse include?
Correct Answer: A
Rationale: The correct answer is A because it provides important information about the expected post-operative outcome related to wound healing. Yellow exudate is a normal part of the healing process, indicating the presence of white blood cells and tissue debris. This knowledge helps the caregiver differentiate between normal and abnormal wound healing.
Choices B, C, and D are incorrect because they do not provide relevant or accurate information related to circumcision care.
Choice B refers to a potential sign of infection or poor circulation, not a routine post-circumcision finding.
Choice C inaccurately states the timing of Plastibell removal, which typically occurs after a few days, not 4 hours.
Choice D is unrelated to circumcision care and may cause discomfort if the diaper is too tight.
Extract:
A client who is postpartum and has a perineal laceration.
Question 4 of 5
Which of the following findings places the client at risk for delayed wound healing?
Correct Answer: A
Rationale: The correct answer is A because changing the perineal pad only once daily can lead to increased moisture and potential for infection, thus delaying wound healing.
Choice B, using witch hazel pads, can actually promote wound healing due to its anti-inflammatory properties.
Choice C, cleaning the perineum with a squeeze bottle, promotes hygiene and wound healing.
Choice D, a well-approximated suture line, indicates good wound closure and does not place the client at risk for delayed healing.
Extract:
A postpartum client who has a prescription for a rubella immunization.
Question 5 of 5
Which of the following client statements indicates understanding of the teaching?
Correct Answer: D
Rationale: The correct answer is D because it demonstrates understanding of the teaching regarding the need to avoid pregnancy for at least 1 month following the immunization to prevent any potential harm to the fetus.
Choice A is incorrect because breastfeeding is not contraindicated after immunization.
Choice B is incorrect because it provides incorrect information about the immunization schedule.
Choice C is incorrect because joint pain is a common side effect of some vaccines and does not necessarily require immediate reporting.