ATI RN
ATI RN Maternal Newborn 2023 II Questions
Extract:
A nurse is providing teaching to the guardians of a preterm newborn about temperature instability.
Question 1 of 5
Which of the following statements should the nurse make?
Correct Answer: A
Rationale: The correct statement is A because preterm newborns have less muscle tone, making them more susceptible to heat loss. This is due to their underdeveloped thermoregulatory mechanisms. Shivering (
B) is not a common response in newborns and is more likely to be seen in adults. Sweating (
C) is also not a common response in newborns as their sweat glands are not fully developed. Brown fat (
D) is essential for thermoregulation in newborns and helps them stay warm, not overheat.
Therefore, A is the correct statement as it directly addresses the vulnerability of preterm newborns to heat loss due to their low muscle tone.
Extract:
A nurse is assessing a client who is 1 hr postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding.
Question 2 of 5
Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Massage the client's fundus. This is the first action the nurse should take after childbirth to prevent postpartum hemorrhage by ensuring the uterus contracts and expels clots. Providing oxygen (
A) is important but not the priority. Emptying the bladder (
B) can help prevent uterine atony, but massaging the fundus is more urgent. Administering oxytocin (
C) can also help prevent hemorrhage, but fundal massage is the initial step.
Extract:
A nurse is teaching about clomiphene citrate to a client who is experiencing infertility.
Question 3 of 5
Which of the following adverse effects should the nurse include?
Correct Answer: A
Rationale: The correct answer is A: Breast tenderness. Breast tenderness is a common adverse effect of hormonal medications like oral contraceptives. It occurs due to hormonal fluctuations and can be bothersome for some individuals. Tinnitus (
B), urinary frequency (
C), and chills (
D) are not typically associated with the side effects of oral contraceptives. Tinnitus is more commonly associated with ototoxic medications, urinary frequency may be seen with diuretics, and chills could be a sign of infection or cold exposure.
Therefore, the nurse should include breast tenderness as a potential adverse effect in the teaching plan.
Extract:
A nurse is caring for a client who has bladder distention following a vaginal birth.
Question 4 of 5
Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Assist the client to the bathroom. This is the first action the nurse should take because it addresses the most immediate need of the client, which is to relieve themselves. It ensures the client's comfort and promotes their dignity. Option B, offering a sitz bath, can be considered later for comfort but does not address the urgent need. Option C, pouring warm water over the client's perineum, may provide relief but does not address the primary need. Option D, inserting a urinary catheter, is an invasive procedure and should only be considered after other non-invasive interventions have been attempted.
Extract:
A nurse is obtaining a 2-hr postprandial blood glucose from a client.
Question 5 of 5
Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Select the lateral side of the finger for puncture. This is because the lateral side has fewer nerve endings, making it less painful for the patient. Puncturing the finger on the lateral side also helps to avoid the central pad where blood flow is better. Holding the finger above the heart (choice
B) is incorrect as it can increase blood flow and dilute the sample. Smearing blood onto the reagent strip (choice
C) is incorrect as it can lead to inaccurate results. Puncturing the finger while still damp with antiseptic solution (choice
D) is incorrect as it can contaminate the blood sample.