ATI RN
ATI RN Maternal Newborn 2023 III Questions
Extract:
A nurse is caring for a postpartum client who just delivered a newborn weighing 4.5 kg (10 lb).
Question 1 of 5
Which of the following signs should the nurse recognize as a potential indication of hemorrhage?
Correct Answer: A
Rationale: A blood pressure of 88/40 mm Hg indicates hypotension, a common sign of significant blood loss such as postpartum hemorrhage, especially after delivering a large newborn which increases risk.
Extract:
A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord.
Question 2 of 5
What clinical findings should the nurse expect?
Correct Answer: A
Rationale: Facial petechiae result from pressure on the face and neck from a nuchal cord, a common finding in such deliveries.
Extract:
A nurse is caring for a client who is in labor. The nurse notes that the umbilical cord is protruding from the client's vagina.
Question 3 of 5
Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: Exerting upward pressure on the presenting part relieves cord compression, restoring fetal blood flow as the priority action.
Extract:
A nurse is caring for a newborn immediately following birth.
Nurse’s Notes (0700 hrs):
• The newborn is a male, born at 38 weeks gestation via vacuum-assisted vaginal birth. The mother has a history of positive group B streptococcus B-hemolytic and received two doses of ampicillin IV bolus during labor.
• The newborn is placed under a radiant warmer.
• Initial assessment shows the newborn is crying weakly.
• The newborn’s skin color is consistent with genetic background but has acrocyanosis.
• Muscle tone is flaccid.
• Reflex irritability is present with a weak cry.
• The newborn’s temperature is 36.3°C (97.4°F).
Vital Signs (0700 hrs):
• Heart rate: 140/min
• Respiratory rate: 60/min
• Axillary temperature: 36.3°C (97.4°F)
• Oxygen saturation: 92%
Laboratory Findings (0700 hrs):
• WBC count: 15,000/mm³ (9,000 to 30,000/mm³)
• Hgb: 19 g/dL (15 to 24 g/dL)
• Hct: 57% (44 to 70%)
• Blood glucose: 44 mg/dL (40 to 60 mg/dL)
Medications (0700 hrs):
• Erythromycin ophthalmic ointment once 1 to 2 hr after birth
• Hepatitis B vaccine 10 mcg/0.5 mL IM once within 24 hr after birth
• Phytonadione 1 mg IM once 1 to 2 hr after birth
Question 4 of 5
A nurse is assessing the newborn 24 hours later. Based on the exhibits provided, which findings indicate that the newborn’s condition is improving, worsening, or unrelated to the diagnosis?
| Findings | condition improving | condition worsening | unrelated to the diagnosis |
|---|---|---|---|
| WBC count 18,000/mm³ | |||
| Hgb 18 g/dL | |||
| Hct 55% | |||
| Blood glucose 50 mg/dL | |||
| . Axillary temperature 36.8°C | |||
| Heart rate 130/min |
Correct Answer:
Rationale: Regurgitation, mottling, RR 70/min, high-pitched cry worsening (NAS symptoms); strabismus unrelated (normal newborn finding).
Extract:
A nurse is caring for a client who is in labor. The nurse observes late decelerations of the fetal heart rate on the external fetal monitor. After placing the client in a side-lying position.
Question 5 of 5
Which of the following actions should the nurse take?
Correct Answer: D
Rationale: Administering oxygen via a face mask increases maternal oxygen saturation, improving fetal oxygenation in response to late decelerations, which indicate fetal hypoxia.