ATI RN
RN ATI Maternal Newborn 2023 with NGN 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: , (B, 0, 1, 0), (C, 1, 0, 1), (D, 0, 0, 0)
- A: Inserting a large bore IV catheter is indicated for emergency situations to provide rapid fluid replacement or administer medications.
- B: Assessing cervical dilation is not indicated unless specifically related to the client's condition, not a routine nursing action.
- C: Weighing perineal pads is indicated to monitor postpartum hemorrhage by measuring blood loss.
- D: Administering methotrexate is contraindicated in the absence of a specific indication or prescription for the client.
Extract:
Question 2 of 5
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
Correct Answer: C
Rationale: The correct answer is C: Assist the client to empty their bladder. Palpating the uterus above the umbilicus indicates uterine atony, which can be caused by a distended bladder pressing on the uterus. Emptying the bladder helps the uterus contract effectively, preventing postpartum hemorrhage.
Choice A is incorrect as immediate intervention is needed.
Choice B (administering simethicone) is irrelevant to the situation.
Choice D (instructing the client to lie on their right side) does not address the underlying issue.
Question 3 of 5
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?
Correct Answer: B
Rationale: The correct answer is B: Chin quivering. Chin quivering is a common indicator of pain in newborns as they are unable to verbally express discomfort. It is a physical sign of distress often observed during painful procedures like circumcision. Decreased heart rate (choice
A), pinpoint pupils (choice
C), and slowed respirations (choice
D) are not specific indicators of pain in newborns and can be influenced by various factors. In contrast, chin quivering is a more reliable and direct sign of pain in this context.
Question 4 of 5
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Report the client's condition to the local health department. This action is crucial to ensure that proper public health measures can be taken to prevent the spread of HIV to others. Reporting the client's condition will also enable the health department to provide necessary support and resources for the client and her baby. Administering penicillin G (choice
A) is not indicated for an HIV-positive client at 22 weeks of gestation. Annual pelvic exams (choice
B) are important but not the priority in this case. Waiting to start HIV medication until after delivery (choice
C) is not recommended as early treatment is essential.
Question 5 of 5
A nurse is admitting a client to the labor and delivery unit when the client states, 'My water just broke.' Which of the following interventions is the nurse's priority?
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. Monitoring fetal heart rate (FHR) is the priority as it assesses the well-being of the baby after the water breaking. A sudden gush of fluid can indicate potential stress on the baby, so immediate monitoring is crucial. Performing Nitrazine testing (choice
A) or assessing the fluid (choice
B) can be done after ensuring the baby's safety. Checking cervical dilation (choice
C) is important but not as urgent as monitoring the FHR.