ATI RN
ATI RN Maternal Newborn Updated 2023 Questions
Extract:
A client following a vaginal delivery of a term fetal demise.
Question 1 of 5
Which of the following statements should the nurse make?
Correct Answer: A
Rationale: The correct answer is A: "You can bathe and dress your baby if you'd like to." This statement empowers the parent to make choices regarding caring for their baby, promoting autonomy and bonding. It fosters a sense of control and involvement in the care process.
Choice B is incorrect as it assumes the parent wants another baby, which may not be the case and can be insensitive.
Choice C is incorrect as it implies that not holding the baby will make it harder to let go, which may not be true for everyone and can induce guilt.
Choice D is incorrect as naming the baby is a personal decision and should not be dictated by others.
Extract:
A client who is at 28 weeks of gestation and received no immunizations during childhood.
Question 2 of 5
Which of the following vaccines should the nurse plan to administer?
Correct Answer: C
Rationale: The correct answer is C: Tetanus. Tetanus vaccine should be administered routinely to prevent tetanus, a serious bacterial infection. The other choices are incorrect because: A: Human papillomavirus vaccine is typically given to prevent HPV-related cancers; B: Rubella vaccine is given to prevent rubella, a viral infection that can cause birth defects; D: Varicella vaccine is given to prevent chickenpox, a viral infection. In this case, the nurse should plan to administer the tetanus vaccine for routine preventive care.
Extract:
A client who is at 32 weeks of gestation and has placenta previa exhibiting a large amount of vaginal bleeding.
Question 3 of 5
Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct action for the nurse to take is to obtain serial hemoglobin and hematocrit levels. This is important for monitoring the patient's blood loss and hemodynamic status after childbirth. Serial monitoring helps in early detection of postpartum hemorrhage and guides appropriate interventions. Giving oxytocin 20 units IV bolus (choice
A) is contraindicated as it can cause severe adverse effects like hypotension and cardiac arrhythmias. Performing a fundal massage (choice
B) is a potential intervention for uterine atony but assessing for abdominal tenderness (choice
C) would be more appropriate to identify possible causes of pain.
Therefore, obtaining serial hemoglobin and hematocrit levels is the most appropriate action to assess and manage postpartum hemorrhage effectively.
Extract:
A newborn who was born via a forceps-assisted birth.
Question 4 of 5
Which of the following findings should the nurse identify as an injury caused by the forceps?
Correct Answer: D
Rationale: The correct answer is D: Facial asymmetry. Forceps during delivery can cause pressure and trauma to the baby's face, leading to facial asymmetry. The forceps compress one side of the face more than the other, resulting in an uneven appearance. Depressed anterior fontanel (
A) is not typically associated with forceps delivery. Uneven gluteal skinfolds (
B) and epicanthal folds (
C) are not specific indicators of forceps injury. In summary, facial asymmetry is a common finding in babies delivered with forceps due to the pressure exerted on the face during delivery.
Extract:
A client who is in labor.
Question 5 of 5
Which of the following findings should prompt the nurse to reassess the client?
Correct Answer: B
Rationale: The correct answer is B. An urge to have a bowel movement during contractions should prompt the nurse to reassess the client because it could indicate the need to push, which could lead to premature delivery. This finding can signal the need for further evaluation to prevent complications. Intense contractions lasting 45 to 60 seconds (
A) are normal during labor. A sense of excitement and warm, flushed skin (
C) can be a normal response to the labor process. Progressive sacral discomfort during contractions (
D) is common due to pressure on the sacrum during labor.