ATI RN Maternal Newborn 2023
Total Questions : 35
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Question 1: View
A nurse is preparing to administer phytonadione 0.5 mg to a newborn. Which of the following routes should the nurse choose for administration of the medication?
Explanation
A. IM in right deltoid:
The deltoid muscle is not typically used for IM injections in newborns. Additionally, the vastus lateralis muscle in the thigh is preferred over the deltoid muscle for IM injections in infants.
B. Subcutaneous in the right deltoid:
Subcutaneous administration is not the preferred route for phytonadione in newborns. Additionally, the deltoid muscle is not commonly used for subcutaneous injections in newborns.
C. IM in left vastus lateralis:
This is the correct choice. The vastus lateralis muscle in the thigh is the preferred site for IM injections in newborns due to its size and accessibility. Administering phytonadione via IM injection in the vastus lateralis muscle allows for optimal absorption of the medication.
D. Subcutaneous in the left vastus lateralis:
Subcutaneous administration is not the preferred route for phytonadione in newborns. Additionally, the vastus lateralis muscle is typically used for IM injections rather than subcutaneous injections in infants.
Question 2: View
A nurse is assessing the results of a nonstress test for an antepartal client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?
Explanation
A. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client.
Irregular contractions alone are not necessarily concerning. However, if they are not felt by the client, it may indicate decreased fetal movement. Further evaluation is needed to ensure the baby’s well-being.
B. 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 period.
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 period:This finding is reassuring.A reactive NST (with accelerations in FHR) indicates that the baby is healthy and responsive to moveme.
C. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period.
The absence of late decelerations during uterine contractions is a positive finding during an NST. Late decelerations, which occur after the peak of the contraction, can indicate uteroplacental insufficiency and fetal hypoxia. Therefore, not observing late decelerations during contractions is reassuring and does not typically necessitate further testing.
D. Three fetal movements perceived by the client in a 20-min testing period.
Perceiving fetal movements during the testing period is generally considered reassuring during an NST. Fetal movements are indicative of fetal well-being and activity. Therefore, this finding is typically interpreted as a positive sign and does not typically require further evaluation during the NST.
A. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client.
Irregular contractions of short duration that are not perceived by the client are not typically concerning during a nonstress test (NST). The primary focus of an NST is to assess fetal heart rate patterns in response to fetal movement and uterine activity. As long as these contractions do not lead to decelerations or other signs of fetal distress, they are not usually indicative of a problem.
B. 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 period.
This is the correct answer. While fetal heart rate accelerations in response to fetal movement are typically reassuring during an NST, an acceleration of 150 beats per minute above the baseline heart rate, lasting 10 seconds, could indicate fetal distress or compromise. Such a significant increase may suggest that the fetus is having difficulty compensating for stress or may be experiencing hypoxia, necessitating further evaluation.
C. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period.
The absence of late decelerations during uterine contractions is a positive finding during an NST. Late decelerations, which occur after the peak of the contraction, can indicate uteroplacental insufficiency and fetal hypoxia. Therefore, not observing late decelerations during contractions is reassuring and does not typically necessitate further testing.
D. Three fetal movements perceived by the client in a 20-min testing period.
Perceiving fetal movements during the testing period is generally considered reassuring during an NST. Fetal movements are indicative of fetal well-being and activity. Therefore, this finding is typically interpreted as a positive sign and does not typically require further evaluation during the NST.
Question 3: View
A nurse is caring for a client who is at 28 weeks of gestation and received no immunizations during childhood. Which of the following vaccines should the nurse plan to administer?
Explanation
A. Human papillomavirus (HPV) vaccine:
The HPV vaccine is not recommended during pregnancy because there is limited safety data regarding its use in pregnant women. It is typically administered to individuals before they become sexually active to prevent HPV infections, which can lead to cervical cancer and other HPV-related diseases. Since the client is currently pregnant, administering the HPV vaccine would not be appropriate due to the lack of safety data during pregnancy.
B. Rubella vaccine:
The rubella vaccine is a live attenuated vaccine, and its administration during pregnancy is contraindicated due to the risk of congenital rubella syndrome (CRS) if the vaccine were to cause rubella infection in the pregnant woman. Rubella vaccination should be provided to non-pregnant individuals, particularly women of childbearing age, to prevent CRS. Administering the rubella vaccine to a pregnant woman at 28 weeks of gestation would pose a risk to both the mother and the developing fetus.
C. Varicella vaccine:
Similar to the rubella vaccine, the varicella (chickenpox) vaccine is a live attenuated vaccine and is contraindicated during pregnancy due to the risk of varicella infection in the pregnant woman, which can lead to severe complications for both the mother and the fetus. Varicella vaccination is recommended for individuals who have not had chickenpox or received the vaccine previously but should not be administered to pregnant women.
D. Tetanus vaccine:
Tetanus vaccination during pregnancy is recommended to prevent maternal and neonatal tetanus. Tetanus toxoid is considered safe during pregnancy and is routinely administered as part of the tetanus-diphtheria-pertussis (Tdap) vaccine. The tetanus vaccine helps protect against tetanus, a potentially fatal bacterial infection. Administering the tetanus vaccine during pregnancy is important for the health and safety of both the mother and the developing fetus.
Question 4: View
A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?
Explanation
Correct answer: D
A. Apply an ice pack to the incision site.
Applying an ice pack to the incision site is not the appropriate action for addressing vaginal bleeding. Ice packs are typically used to reduce swelling and provide comfort after surgery, but they are not effective for controlling bleeding. In this scenario, the primary concern is the steady trickle of vaginal bleeding, which could indicate postpartum hemorrhage (PPH). Therefore, applying an ice pack would not address the underlying issue and is not the correct action to take at this time.
B. Administer 500 mL lactated Ringer's IV bolus.
Administering a lactated Ringer's IV bolus may be necessary if the client is experiencing hypovolemia due to excessive bleeding. However, before administering fluids, it is important to address the source of bleeding. While IV fluids may be indicated as part of the treatment for postpartum hemorrhage, they should be given after assessing the extent of bleeding and determining the appropriate management. Therefore, while fluid resuscitation may eventually be necessary, it is not the immediate priority in this scenario.
C.Replace the surgical dressing. This action addresses the surgical site but does not directly relate to managing vaginal bleeding.
D. Evaluate urinary output. A steady trickle of vaginal bleeding that does not stop with fundal massage can indicate uterine atony or other postpartum complications such as retained placental fragments or cervical/vaginal lacerations. Evaluating urinary output is important because a full bladder can prevent the uterus from contracting effectively, contributing to continued bleeding. Ensuring the bladder is empty may help the uterus contract more effectively and reduce bleeding.
Question 5: View
- A nurse is assessing a postpartum client who delivered vaginally 8 hr ago.
Exhibit 1
Nurses' Notes
0700:
Breasts soft, nipples intact. Uterus palpated firm, midline, and at level of umbilicus. Moderate amount of lochia rubra. Episiotomy site well approximated with mild edema and ecchymosis. Client reports pain as 2 on a scale of 0 to 10. Able to void spontaneously; no bladder distention. Deep tendon reflexes 1+. Peripheral edema 2+ in bilateral lower extremities.
1100:
Breasts soft, nipples intact. Uterus palpated soft with lateral deviation and 1 cm above the umbilicus. Large amount of lochia rubra. Episiotomy site well approximated with mild edema and ecchymosis. Client reports pain as 3 on a scale of 0 to 10. Deep tendon reflexes 1+ Peripheral edema 2+ in bilateral lower extremities.
Exhibit 2
0700:
Temperature 36.2" C (97.2" F) Pulse rate 80/min
Respiratory rate 16/min
Blood pressure 136/82 mm Hg
Pulse oximetry 99%
1100:
Temperature 37.2° C (99.0° F)
Pulse rate 85/min
Respiratory rate 18/min
Blood pressure 136/86 mm Hg
Pulse oximetry 100%
Select the 3 findings that require immediate follow-up.
Explanation
A. Uterine tone soft:A soft uterus can indicate inadequate uterine contraction, which may increase the risk of postpartum hemorrhage. The uterus should be firm and well-contracted after delivery.
B. Blood pressure 136/86 mm Hg:
A blood pressure of 136/86 mm Hg is within the normal range for a postpartum client. While changes in blood pressure should be monitored, this reading alone does not indicate an urgent need for follow-up.
C. Peripheral edema 2+ bilateral lower extremities:
Peripheral edema is a common finding in the postpartum period and is often attributed to fluid shifts and hormonal changes. While it should be monitored, it does not typically require immediate follow-up unless it is severe or associated with other symptoms.
D. Large amount of lochia rubra: While lochia rubra is normal in the first few days postpartum, a large amount could indicate potential bleeding issues or complications if it increases significantly.
E. Pain rating of 3 on a scale of 0 to 10:
A pain rating of 3 on a scale of 0 to 10 is relatively mild and may be expected after a vaginal delivery, especially if the client has undergone an episiotomy. It should be addressed but does not require immediate follow-up unless it worsens or is associated with other concerning symptoms.
F. Breasts soft:
Soft breasts are expected in the early postpartum period, particularly if the client is not breastfeeding or if breastfeeding has not yet been established. However, breastfeeding assessment and support should be provided as part of routine postpartum care.
G. Lateral deviation of the uterus:The uterus should be midline and firm. A lateral deviation could suggest a full bladder or other complications that need to be addressed to prevent further issues such as postpartum hemorrhage.
H. Deep tendon reflexes 1+:
Deep tendon reflexes of 1+ are within the normal range and do not typically require immediate follow-up unless they are absent or hyperactive, which may indicate neurological issues.
Question 6: View
A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?
Explanation
A. Move the client onto their hands and knees.
This action refers to the Gaskin maneuver, which involves changing the maternal position to help alleviate shoulder dystocia during childbirth. By positioning the client on their hands and knees, gravity assists in changing the orientation of the pelvis, potentially allowing more space for the baby to be delivered. While the Gaskin maneuver can be effective in some cases of shoulder dystocia, it is not the McRoberts maneuver.
B. Press firmly on the client's suprapubic area.
This action describes the Rubin maneuver, another technique used to address shoulder dystocia. With the Rubin maneuver, pressure is applied to the anterior shoulder of the fetus, aiming to rotate it into an oblique diameter, which may help dislodge the shoulder from behind the symphysis pubis. While the Rubin maneuver can be helpful in certain cases of shoulder dystocia, it is not the McRoberts maneuver.
C. Apply pressure to the client's fundus.
Applying pressure to the client's fundus is not part of the McRoberts maneuver. In fact, this action is not recommended for managing shoulder dystocia as it could potentially worsen the situation by causing further impaction of the baby's shoulder against the mother's pubic bone.
D. Assist the client in pulling their knees toward their abdomen.
This is the correct action corresponding to the McRoberts maneuver. During the McRoberts maneuver, the nurse assists the client in flexing their hips sharply toward their abdomen. This action helps to widen the pelvic outlet and may facilitate the release of the impacted shoulder, allowing for easier delivery of the baby. The McRoberts maneuver is one of the primary maneuvers used to manage shoulder dystocia during childbirth.
Question 7: View
A nurse is caring for a client who is experiencing infertility and is requesting in vitro fertilization. Which of the following information should the nurse provide to the client?
Explanation
A. Inform the client about the possible need for reduction of multiple fetuses:
In vitro fertilization (IVF) can lead to the development of multiple embryos, increasing the risk of multiple gestation pregnancies, such as twins or triplets. Multiple gestations pose higher risks for both the mother and the babies, including preterm birth, low birth weight, and other complications. Therefore, the nurse should inform the client about the possibility of needing fetal reduction procedures to reduce the number of fetuses and minimize risks to both the mother and the remaining babies.
B. Instruct the client not to use donor oocytes:
Donor oocytes (eggs) are commonly used in IVF procedures, particularly for clients who have infertility related to egg quality or production issues. The decision to use donor oocytes should be based on individual circumstances and preferences. It is not appropriate for the nurse to instruct the client not to use donor oocytes without knowing the client's specific situation and preferences.
C. Instruct the client to avoid freezing embryos for possible use in the future:
Freezing embryos for future use, known as embryo cryopreservation, is a common practice in IVF. It allows for the preservation of embryos that are not transferred during the initial IVF cycle for potential use in subsequent cycles. Embryo cryopreservation can improve the chances of pregnancy without the need for additional ovarian stimulation and egg retrieval procedures. Therefore, instructing the client to avoid freezing embryos would not be appropriate advice.
D. Inform the client that sperm will be introduced to the uterus during ovulation:
This statement is incorrect. In IVF, fertilization typically occurs outside the body in a laboratory setting. The eggs retrieved from the ovaries are fertilized with sperm in a dish, and the resulting embryos are then transferred to the uterus. Sperm is not introduced to the uterus during ovulation in the context of IVF.
Question 8: View
A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider?
Explanation
. A client who reports lochia rubra requiring changing perineal pads every 3 hr:
This finding is consistent with normal postpartum lochia patterns, particularly in the early postpartum period. Lochia rubra is the initial bright red vaginal discharge that occurs after childbirth, and changing perineal pads every 3 hours is within the expected range. There is no immediate concern requiring notification of the provider for this client.
B. A client who reports abdominal cramping during breastfeeding:
Abdominal cramping during breastfeeding, also known as afterpains, is a common occurrence in the postpartum period, especially for multiparous clients. These cramps are caused by the release of oxytocin during breastfeeding and help the uterus to contract and return to its pre-pregnancy size. While uncomfortable, afterpains are considered normal and do not typically require notification of the provider unless they are severe or accompanied by other concerning symptoms.
C. A client who has a urinary output of 300 mL in 8 hr:
This urinary output is below the expected range for a postpartum client, and it may indicate inadequate fluid intake, urinary retention, or other issues. While it is important to monitor urinary output and address any potential concerns, this finding alone may not require immediate notification of the provider. However, continued monitoring and assessment are warranted to ensure adequate urinary function.
D. A client who is receiving magnesium sulfate and has absent deep tendon reflexes:
Absent deep tendon reflexes are an indication of magnesium toxicity, which is a serious complication of magnesium sulfate administration. Magnesium sulfate is commonly used to prevent seizures in clients with preeclampsia or eclampsia. However, excessive levels of magnesium can lead to respiratory depression, cardiac arrest, and other adverse effects. Absent deep tendon reflexes are an early sign of magnesium toxicity and require immediate intervention, including discontinuation of magnesium sulfate and close monitoring of the client's respiratory and cardiac status. Therefore, the nurse should notify the provider immediately for further guidance and management.
Question 9: View
A nurse is reviewing the history of a client who is pregnant. Which of the following clinical data indicates the client is at risk for preterm delivery?
Explanation
A. Previous cervical cerclage:
Cervical cerclage is a surgical procedure performed to reinforce the cervix in women with a history of cervical insufficiency or cervical incompetence. Cervical insufficiency is a condition where the cervix begins to dilate prematurely, leading to an increased risk of preterm birth. By placing a cervical cerclage, the risk of preterm delivery due to cervical insufficiency is reduced. Therefore, a history of previous cervical cerclage indicates an increased risk for preterm delivery in subsequent pregnancies.
B. Previous delivery of a newborn weighing 2.5 kg (5.5 lb):
A newborn weighing 2.5 kg (5.5 lb) at birth suggests that the infant was small for gestational age (SGA). While SGA infants may be at risk for various complications, such as intrauterine growth restriction (IUGR), it does not directly indicate an increased risk for preterm delivery in subsequent pregnancies. Therefore, this choice is not indicative of preterm delivery risk.
C. Previous reactive non-stress test:
A reactive non-stress test (NST) is a reassuring finding during pregnancy and indicates that the fetus is receiving adequate oxygenation and is not under distress. While the absence of a reactive NST might indicate fetal compromise and the need for further evaluation, a previous reactive NST does not necessarily indicate an increased risk for preterm delivery.
D. Previous delivery at 37 weeks gestation:
A delivery at 37 weeks gestation is considered full-term and does not indicate an increased risk for preterm delivery. In fact, delivering at 37 weeks is within the normal range of gestational age and is not typically associated with preterm birth risk factors. Therefore, this choice does not indicate an increased risk for preterm delivery.
Question 10: View
A nurse on a labor and delivery unit is providing teaching to a client who plans to use hypnosis to control labor pain. Which of the following Information should the nurse Include?
Explanation
A. "Hypnosis can be beneficial if you practiced it during the prenatal period":
This statement is accurate. Hypnosis techniques for pain management during labor can be more effective if the client has practiced and familiarized themselves with the techniques during the prenatal period. Regular practice can help the client achieve a deeper state of relaxation and better utilize hypnosis for pain control during labor.
B. "Synchronized breathing will be required during hypnosis":
While synchronized breathing techniques can be part of hypnosis practice, it is not necessarily a requirement for hypnosis to be effective for pain management during labor. Different hypnosis techniques may focus on various aspects such as visualization, deep relaxation, or suggestion to manage pain.
C. "Focusing on controlling body functions will be helpful during hypnosis":
While focusing on controlling body functions, such as breathing or muscle tension, can be part of hypnosis techniques, it is not the only focus. Hypnosis for pain management during labor often involves guiding the mind to a state of deep relaxation and altering perceptions of pain rather than directly controlling body functions.
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