ATI RN
ATI RN Maternal Newborn Updated 2023 Questions
Extract:
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?
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 newborn who was born via a forceps-assisted birth.
Question 2 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 taking an oral contraceptive.
Question 3 of 5
The nurse should instruct the client to report which of the following findings to the provider immediately?
Correct Answer: B
Rationale: The correct answer is B: Persistent headaches. Headaches can indicate serious conditions like hypertension or preeclampsia, requiring immediate medical attention to prevent complications. Breast tenderness, vaginal itching, and painful intercourse are common discomforts during pregnancy but typically not urgent issues. Reporting persistent headaches promptly can ensure timely intervention and prevent potential risks to the client and fetus.
Extract:
A client who is postpartum and just delivered a newborn who weighs 4.5 kg (10 lb).
Question 4 of 5
Which of the following manifestations should the nurse recognize as a potential sign of hemorrhage?
Correct Answer: A
Rationale: The correct answer is A. A blood pressure of 88/40 mm Hg is indicative of hypotension, which is a common sign of hemorrhage due to decreased blood volume. Hypotension results from the body's compensatory mechanisms to maintain perfusion. Options B, C, and D are not specific indicators of hemorrhage. Urinary output of 40 mL/hr is within normal range, moderate rubra lochia is expected in the postpartum period, and a heart rate of 90/min is not necessarily abnormal. It is crucial for the nurse to recognize hypotension as a potential sign of hemorrhage to intervene promptly and prevent further complications.
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.