ATI RN Maternal Newborn 2023 IV

Extract:

A nurse is preparing to administer phytonadione 0.5 mg to a newborn.

Question 1 of 5

Which of the following routes should the nurse choose for administration of the medication?

A. IM in right deltoid B. Subcutaneous in the right deltoid C. IM in left vastus lateralis D. Subcutaneous in the left vastus lateralis

Correct Answer: C

Rationale: The vastus lateralis muscle in the thigh is the preferred site for IM injections in newborns due to its size and accessibility. Phytonadione (Vitamin K) is administered IM, not subcutaneously, and the deltoid is not used in newborns.

Extract:

A nurse is assessing the results of a nonstress test for an antepartal client at 35 weeks of gestation.

Question 2 of 5

Which of the following findings should indicate to the nurse the need for further diagnostic testing?

A. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client B. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period C. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period D. Three fetal movements perceived by the client in a 20-min testing period

Correct Answer: A

Rationale: Irregular contractions not felt by the client may indicate decreased fetal movement, warranting further evaluation. The other findings (reactive NST, no late decelerations, fetal movements) are reassuring.

Extract:

A nurse is caring for a client who is at 28 weeks of gestation and received no immunizations during childhood.

Question 3 of 5

Which of the following vaccines should the nurse plan to administer?

A. Human papillomavirus B. Rubella C. Varicella D. Tetanus

Correct Answer: D

Rationale: Tetanus vaccination (Tdap) is safe and recommended during pregnancy to prevent maternal and neonatal tetanus. HPV, rubella, and varicella vaccines are contraindicated due to lack of safety data or live virus content.

Extract:

A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage.

Question 4 of 5

Which of the following actions should the nurse take?

A. Apply an ice pack to the incision site. B. Administer 500 mL lactated Ringer's IV bolus C. Replace the surgical dressing D. Evaluate urinary output.

Correct Answer: B

Rationale: Administering a lactated Ringer's bolus restores fluid volume and stabilizes blood pressure due to persistent bleeding, addressing the immediate concern of fluid loss.

Extract:

A nurse is assessing a postpartum client who delivered vaginally 8 hr ago. Nurses' Notes: 0700: Breasts soft, nipples intact. Uterus firm, midline, at umbilicus. Moderate lochia rubra. Episiotomy well approximated, mild edema, ecchymosis. Pain 2/10. Able to void, no bladder distention. DTR 1+. Peripheral edema 2+ in legs. 1100: Breasts soft, nipples intact. Uterus soft, laterally deviated, 1 cm above umbilicus. Large lochia rubra. Pain 3/10. DTR 1+. Peripheral edema 2+ in legs. Vital Signs: 0700: Temp 36.2Â°C, Pulse 80/min, RR 16/min, BP 136/82 mmHg, SpO2 99%. 1100: Temp 37.2Â°C, Pulse 85/min, RR 18/min, BP 136/86 mmHg, SpO2 100%.

Question 5 of 5

Select the 3 findings that require immediate follow-up.

A. Uterine tone soft B. Blood pressure 136/86 mm Hg C. Peripheral edema 2+ bilateral lower extremities D. Large amount of lochia rubra E. Pain rating of 3 on a scale of 0 to 10 F. Breasts soft G. Lateral deviation of the uterus

Correct Answer: A, D, G

Rationale: A soft uterus (
A) risks postpartum hemorrhage. Large lochia rubra (
D) may indicate bleeding issues. Lateral uterine deviation (G) suggests a full bladder or complication. BP, edema, pain, and soft breasts are within normal limits.

ATI RN Maternal Newborn 2023 IV | Nurselytic

Nurselytic

ATI RN

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