ATI RN Maternal Newborn 2023 at Baton Rouge Community College

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Free ATI RN Maternal Newborn 2023 at Baton Rouge Community College Questions

1.

A nurse is assessing a newborn who is 2 days old. Which of the following findings should the nurse report to the provider?

  • Head circumference increase of 1 cm (0.4 in) since birth
  • Heart rate 165/min when crying
  • Greenish-brown thin stools with visible milk curds
  • Presence of a Babinski reflex

Explanation

Explanation
A rapid increase in head circumference during the first few days of life is abnormal and may indicate serious conditions such as intracranial hemorrhage, hydrocephalus, or cerebral edema. Newborn head circumference should remain relatively stable after birth. An increase of 1 cm within 48 hours requires prompt provider notification and further evaluation to rule out neurological complications.
Correct Answer Is:
A. Head circumference increase of 1 cm (0.4 in) since birth.
2.

A nurse is caring for a client who is in labor and has spontaneous rupture of membranes. The nurse notes that the umbilical cord is protruding from the client’s vagina. After calling for help, which of the following actions should the nurse take first?

  • Wrap the cord in a sterile towel and moisten with warm sterile normal saline.
  • Use fingers to exert upward pressure on the presenting part.
  • Administer a tocolytic medication.
  • Apply oxygen via facemask to the client.

Explanation

Explanation
Umbilical cord prolapse is an obstetric emergency because compression of the cord reduces fetal oxygenation and can quickly lead to hypoxia or fetal death. The nurse’s immediate priority is to relieve pressure on the umbilical cord by inserting two fingers into the vagina and manually elevating the presenting part off the cord. This action helps restore blood flow through the cord until definitive treatment, usually an emergency cesarean birth, can be performed. Other interventions, such as oxygen administration or covering the cord with saline-soaked gauze, are supportive but do not take priority over relieving cord compression.
Correct Answer Is:
B. Use fingers to exert upward pressure on the presenting part.
3.

A nurse is planning care for a client who is receiving epidural opioids during a cesarean birth. Which of the following assessments is the nurse's priority for the first 24 hr following birth?

  • Urinary output
  • Respiratory status
  • Heart rate
  • Pain level

Explanation

Explanation
Epidural opioids can cause delayed respiratory depression, which may occur several hours after administration and can be life-threatening if not promptly identified. For the first 24 hours following a cesarean birth, the nurse’s highest priority is closely monitoring respiratory rate, depth, and oxygen saturation. Early detection of hypoventilation allows for rapid intervention and prevents serious complications such as hypoxia, making respiratory assessment the top priority over pain, cardiac status, or urinary output.
Correct Answer Is:
B. Respiratory status.
4.

A nurse is caring for a client who is at 20 weeks of gestation and reports constipation. Which of the following recommendations should the nurse make to help relieve this common discomfort of pregnancy?

  • Add 30 mL of mineral oil to each meal.
  • Drink 2 to 3 L of water each day.
  • Include 18 g of fiber in the diet each day.
  • Take 60 mL of magnesium hydroxide once daily.

Explanation

Explanation
Adequate fluid intake is a first-line, nonpharmacological intervention for constipation during pregnancy. Drinking 2 to 3 liters of water daily helps soften stool, promote regular bowel movements, and reduce straining. Increased hydration works synergistically with dietary fiber and physical activity to improve gastrointestinal motility, making it a safe and effective recommendation for pregnant clients experiencing constipation.
Correct Answer Is:
B. Drink 2 to 3 L of water each day.
5.

A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?
(Select All That Apply.)

  • Exaggerated Moro reflex
  • Acrocyanosis
  • Tachypnea
  • Shrill pitched cry
  • Hypotonia

Explanation

Explanation

A. Exaggerated Moro reflex
Newborns with neonatal abstinence syndrome commonly exhibit neurologic hyperexcitability due to withdrawal from substances such as opioids. This hyperexcitability results in exaggerated reflexes, including an exaggerated Moro reflex. The infant may startle easily and display excessive motor responses to minimal stimulation.

C. Tachypnea
Tachypnea is a frequent finding in neonatal abstinence syndrome and reflects autonomic nervous system dysregulation. Withdrawal increases metabolic demands and sympathetic nervous system activity, leading to rapid breathing. Persistent tachypnea can also contribute to feeding difficulties and increased caloric expenditure.

D. Shrill pitched cry
A high-pitched, shrill cry is a classic and hallmark sign of neonatal abstinence syndrome. It occurs due to central nervous system irritability and heightened sensitivity to environmental stimuli. This type of cry is often persistent, difficult to console, and serves as an important clinical indicator of withdrawal severity.


Correct Answer Is:
A. Exaggerated Moro reflex
C. Tachypnea
D. Shrill pitched cry.
6.

A nurse manager is revising a maternal unit policy to ensure proper identification of newborns. Which of the following should the nurse include in the policy?

  • Obtain an imprint of the infant's feet prior to taking him to the nursery.
  • Require visitors to wear an identification band.
  • Replace the infant's identification band after his name has been recorded.
  • Check the newborn's identification using the crib card.

Explanation

Explanation
Obtaining a footprint of the newborn before separation from the parent is an accepted supplemental identification measure that helps ensure correct identification. Although identification bands are the primary method, footprints provide an additional layer of verification if bands are lost or questioned. Newborn identification must occur immediately after birth and before transport to reduce the risk of misidentification.
Correct Answer Is:
A. Obtain an imprint of the infant's feet prior to taking him to the nursery.
7.

A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?

  • Absent Moro reflex
  • High-pitched crying
  • Diminished deep tendon reflexes
  • Decreased muscle tone

Explanation

Explanation
Neonatal abstinence syndrome occurs when a newborn withdraws from substances, most commonly opioids, that were used during pregnancy. A hallmark manifestation of withdrawal is a high-pitched, shrill cry caused by central nervous system hyperirritability. Affected newborns are often difficult to console and may cry excessively. Reflexes are typically exaggerated rather than absent, and muscle tone is usually increased rather than decreased.
Correct Answer Is:
B. High-pitched crying.
8.

A nurse is caring for a newborn 4 hr after birth. Which of the following findings should the nurse report to the provider?

  • Pale blue hands and feet
  • Soft grunting noises with respiration
  • Blood-tinged discharge from the vagina
  • Positive Babinski reflex

Explanation

Explanation
Grunting is an abnormal respiratory finding in a newborn and indicates respiratory distress. It occurs when the newborn partially closes the glottis during expiration in an attempt to maintain positive airway pressure and improve oxygenation. Even soft or intermittent grunting can signal conditions such as retained lung fluid, respiratory distress syndrome, or infection. This finding requires prompt evaluation and intervention to prevent worsening hypoxia and respiratory failure.
Correct Answer Is:
B. Soft grunting noises with respiration.
9.

A nurse is caring for a client who is in labor at 38 weeks of gestation.

Exhibit 1

Nurses' Notes

0900:

Client reports a gush of fluid from between their legs.

0930:

FHR: 90/min with absent variability

0931:

Prolonged deceleration noted.

Umbilical cord visible. Called for assistance.


After reviewing the assessment findings, which of the following actions should the nurse take?
(Select the 3 actions the nurse should take.)

  • Administer oxygen therapy via nonrebreather mask.
  • Assist the client into the Trendelenburg position.
  • Apply suprapubic pressure.
  • Increase the intravenous fluid rate.
  • Replace the cord into the cervix.

Explanation

Explanation

A. Administer oxygen therapy via nonrebreather mask.
With a fetal heart rate of 90/min, absent variability, and a prolonged deceleration, the fetus is showing signs of significant compromise likely from cord compression and reduced oxygen delivery. Administering high-flow oxygen by nonrebreather mask increases maternal oxygenation and improves the amount of oxygen available for placental transfer. This is an immediate intrauterine resuscitation measure while preparing for urgent delivery.

B. Assist the client into the Trendelenburg position.
A visible umbilical cord indicates cord prolapse, which is an obstetric emergency because the presenting part can compress the cord and cut off fetal blood flow. Trendelenburg positioning uses gravity to move the fetus off the cord, decreasing compression and helping restore perfusion. This intervention is initiated immediately while awaiting definitive management, typically an emergent cesarean birth.

D. Increase the intravenous fluid rate.
Increasing IV fluids supports maternal circulating volume and improves uteroplacental perfusion, which can help stabilize fetal status during a nonreassuring tracing. With cord prolapse and fetal bradycardia, optimizing maternal blood flow is a key supportive intervention. A fluid bolus can help correct hypotension if present or prevent further compromise while the team prepares for rapid delivery.


Correct Answer Is:
A. Administer oxygen therapy via nonrebreather mask.
B. Assist the client into the Trendelenburg position.
D. Increase the intravenous fluid rate.
10.

A nurse is caring for a client who has a prescription for metronidazole 250 mg PO three times daily. Available is metronidazole 500 mg tablets. How many tablet(s) should the nurse plan to administer per dose?
(Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

  • 0.25 tablet
  • 0.5 tablet
  • 1 tablet
  • 2 tablets

Explanation

Explanation
The prescribed dose is 250 mg, and the available tablet strength is 500 mg. To calculate the number of tablets needed, divide the prescribed dose by the available dose: 250 mg ÷ 500 mg = 0.5 tablet. This means the nurse should administer half of a tablet per dose. Rounded to the nearest tenth, the correct amount remains 0.5 tablet.
Correct Answer Is:
B. 0.5 tablet.

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