ATI RN Maternal Newborn 2023 IV

Extract:

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

Question 1 of 5

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

A. Human papillomavirusB. RubellaC. VaricellaD. 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 planning care for a client who is 1 hr postpartum and has preeclampsia without severe features.

Question 2 of 5

Which of the following actions should the nurse plan to take?

A. Assess for edema.B. Administer an IV bolus of lactated Ringer's.C. Restrict daily oral fluid intake.D. Obtain a prescription for misoprostol.

Correct Answer: A

Rationale: Assessing for edema monitors for worsening preeclampsia, a key action in the early postpartum period. Fluid bolus, restriction, and misoprostol are not indicated without severe features.

Extract:

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

Question 3 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 clientB. 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 periodC. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing periodD. 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 preparing to administer phytonadione 0.5 mg to a newborn.

Question 4 of 5

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

A. IM in right deltoidB. Subcutaneous in the right deltoidC. IM in left vastus lateralisD. 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 newborn 24 hr later after a vacuum-assisted vaginal birth. Maternal GBS positive, received ampicillin. Apgar: HR 96/min, weak cry, some flexion, grimace, acrocyanosis, Temp 36.9Â°C. Labs: WBC 15,000/mmÂ³, Hgb 19 g/dL, Hct 57%, Glucose 44 mg/dL.

Question 5 of 5

How should the nurse interpret the findings? (For each finding, specify if unrelated, improving, or worsening.)

A. A: Muscle tone flaccid - Worsening, B: Color consistent - Unrelated, C: HR 140 bpm - Improving, D: Temp 36.9Â°C - UnrelatedB. A: Muscle tone flaccid - Improving, B: Color consistent - Worsening, C: HR 140 bpm - Unrelated, D: Temp 36.9Â°C - WorseningC. A: Muscle tone flaccid - Unrelated, B: Color consistent - Improving, C: HR 140 bpm - Worsening, D: Temp 36.9Â°C - ImprovingD. A: Muscle tone flaccid - Worsening, B: Color consistent - Improving, C: HR 140 bpm - Unrelated, D: Temp 36.9Â°C - Worsening

Correct Answer: A

Rationale: A: Flaccid tone (worsening) suggests decline from 'some flexion'. B: Color consistent (unrelated) is normal variation. C: HR 140 bpm (improving) is better than 96/min. D: Temp 36.9Â°C (unrelated) is stable and normal.

ATI RN Maternal Newborn 2023 IV | Nurselytic

Nurselytic

ATI RN

ATI RN