ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
“A nurse on an antepartum unit is caring for a client.
Exhibit1:
Nurses' Notes 0900:Client reports a small amount of bright red blood in their underwear upon
awakening. Client denies contractions or abdominal pain. External fetal monitor applied.
0930:Client passed large amount of bright red blood from vagina.
Denies pain Uterine tone soft and nontender to palpation.
contraction pattern, no contractions noted.
Fetal heart rate pattern: Fetal heart rate baseline 135/min.
Moderate variability. No decelerations noted.
Exhibit2:
Vital Signs 0900: Temperature 36.2°C (97.2° F) Pulse rate 78/min Respiratory rate 20/min Blood pressure
112/64 mm Hg Fetal heart rate 132/min Pulse rate 82/min Blood pressure 116/60 mm Hg Fetal heart
rate 160/min
Exhibit3:
Medical History. G4P3 30 weeks gestation Previous pregnancies delivered via cesarean section
Question 1 of 5
Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify it the intervention is indicated or contraindicated for the client.
| Potential Nursing Action | Indicated | Contraindicated | |
|---|---|---|---|
| Insert a large bore intravenous catheter. | |||
| Assess cervical dilation. | |||
| Weigh perineal pads. | |||
| Administer methotrexate. |
Correct Answer: A, C
Rationale: [1, 0, 1]
Inserting a large bore intravenous catheter is indicated for the client to establish a rapid intravenous access for fluid resuscitation or medication administration. Weighing perineal pads (
C) is important to monitor postpartum blood loss. Assessing cervical dilation (
B) is not indicated as it is not relevant in this scenario. Administering methotrexate (
D) is contraindicated as it is a medication used for medical abortions and is not applicable in this context.
Extract:
Question 2 of 5
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?
Correct Answer: A
Rationale: The correct answer is A: Administer broad-spectrum antibiotics. This is crucial to prevent infection in the exposed neural tissue. Myelomeningocele increases the risk of meningitis due to the breach in the protective layers of the spinal cord. Administering antibiotics helps to prevent bacterial invasion and subsequent infection. Monitoring rectal temperature is not directly related to the myelomeningocele issue. Cleaning the site with povidone-iodine may cause further irritation to the exposed tissue. Immediate surgical closure is usually necessary to prevent infection; waiting 72 hours is not appropriate in this case.
Question 3 of 5
A nurse is teaching about car seat safety to the parents of a newborn who was delivered at 38 weeks of gestation. Which of the following statements by a parent indicates an understanding of the teaching?
Correct Answer: C
Rationale:
Correct Answer: C - The car seat should be positioned in the car at a 45-degree angle.
Rationale: Placing the car seat at a 45-degree angle is crucial for newborns and premature babies as it helps prevent their head from falling forward, ensuring proper breathing and airway protection. This angle also supports the baby's developing spine and neck muscles. It is a key safety measure recommended for all infants, particularly those born prematurely, to reduce the risk of oxygen desaturation and apnea episodes during travel.
Other
Choices:
A: Using a sleep sack in the car seat may cause overheating and compromise the baby's safety.
B: A car seat challenge test is typically done for preterm infants, not babies born at 38 weeks.
D: Turning a baby's car seat forward-facing at 1 year old is not recommended as rear-facing is safer until at least 2 years old.
Question 4 of 5
A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?
Correct Answer: B
Rationale: The correct answer is B: Transmission can occur via the saliva and urine of the newborn. Cytomegalovirus (CMV) can be transmitted through bodily fluids such as saliva, urine, blood, and breast milk. This is important information for nurses to be aware of as they care for newborns who may be infected.
Explanation for other choices:
A: Mothers do not receive prophylactic treatment with acyclovir for CMV, as there is no specific antiviral treatment for this virus.
C: Lesions on the mother's genitalia are not a typical feature of CMV infection.
D: Airborne precautions are not required for CMV as it is primarily transmitted through bodily fluids, not through the air.
Question 5 of 5
A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?
Correct Answer: C, D
Rationale: The correct answer is C: Bradypnea and D: Vomiting. SSRI withdrawal in newborns can manifest as respiratory distress (bradypnea) and gastrointestinal symptoms such as vomiting. This is due to the sudden discontinuation of the medication after birth, leading to withdrawal symptoms.
Choices A and B are not typical manifestations of SSRI withdrawal. Large for gestational age and hyperglycemia are not directly associated with SSRI use.
Choices E, F, and G are not provided in the question.