ATI RN Maternal Newborn 2023 at Baton Rouge Community College

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Ace Your Test with ATI_RN MATERNAL NEWBORN 2023 Actual Questions and Solutions - Full Set

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

1.

A nurse is assessing a client who is at 37 weeks of gestation. Which of the following statements by the client requires immediate intervention by the nurse?

  • A. “I didn't have lunch today, but I had breakfast this morning.”
  • B. “I have been seeing spots this morning.”
  • C. “My feet are really swollen today.”
  • D. “It burns when I urinate.”

Explanation

Explanation
Seeing spots or visual disturbances during pregnancy is a danger sign of preeclampsia, a potentially life-threatening hypertensive disorder. Visual changes indicate possible cerebral edema or vasospasm and place the client at risk for seizures (eclampsia). At 37 weeks of gestation, this symptom requires immediate assessment of blood pressure, urine protein, and neurologic status, as well as prompt provider notification to protect both maternal and fetal safety.
Correct Answer Is:
B. “I have been seeing spots this morning.”
2.

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.)

  • A. 0.25 tablet
  • B. 0.5 tablet
  • C. 1 tablet
  • D. 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.
3.

A nurse is caring for a client who is 1 hr postpartum and has uterine atony. The client is exhibiting a large amount of vaginal bleeding. Which of the following actions should the nurse take?

  • A. Obtain a specimen for a Kleihauer-Betke test.
  • B. Perform a fundal massage.
  • C. Assess for abdominal tenderness.
  • D. Avoid performing sterile vaginal examinations.

Explanation

Explanation
Uterine atony is the most common cause of postpartum hemorrhage and occurs when the uterus fails to contract effectively after delivery. A firm, contracted uterus compresses blood vessels at the placental site and limits bleeding. The nurse’s priority intervention is to perform a fundal massage to stimulate uterine contractions and promote uterine firmness. Prompt fundal massage can significantly reduce bleeding and prevent progression to severe hemorrhage.
Correct Answer Is:
B. Perform a fundal massage.
4.

A nurse is assessing a newborn who is 2 hr old. Which of the following findings is an indication of hypoglycemia?
(Select All That Apply.)

  • A. Acrocyanosis
  • B. Hypotonia
  • C. Jitteriness
  • D. Temperature instability
  • E. Abdominal distention

Explanation

Explanation

B. Hypotonia
Hypotonia is a common sign of neonatal hypoglycemia and reflects inadequate glucose supply to the central nervous system. Low blood glucose levels impair neuromuscular function, leading to decreased muscle tone, lethargy, and poor feeding. This finding is concerning in the early newborn period and warrants prompt blood glucose evaluation and intervention.

C. Jitteriness
Jitteriness is a classic and early manifestation of neonatal hypoglycemia. It occurs due to increased neuromuscular excitability caused by insufficient glucose available to the brain. Unlike seizures, jitteriness typically stops when the affected limb is held. Persistent jitteriness in a newborn should prompt immediate assessment of blood glucose levels.

D. Temperature instability
Newborns rely heavily on glucose for thermoregulation. Hypoglycemia can impair the newborn’s ability to maintain body temperature, resulting in temperature instability, including hypothermia. This finding is especially significant in the first hours after birth and may be one of the earliest signs of low blood glucose requiring prompt evaluation and treatment.


Correct Answer Is:
B. Hypotonia
C. Jitteriness
D. Temperature instability.
5.

A nurse is assessing a client who is receiving oxytocin via continuous IV infusion for labor augmentation. The nurse notes six contractions in a 10-minute period with a non-reassuring fetal heart rate (FHR) tracing. Which of the following actions should the nurse take first?

  • A. Turn the client to their left side.
  • B. Apply oxygen at 10 L/min via face mask.
  • C. Administer terbutaline 0.25 mg subcutaneously.
  • D. Discontinue the oxytocin IV infusion.

Explanation

Explanation
The client is experiencing uterine tachysystole (more than five contractions in 10 minutes) with a non-reassuring FHR, indicating fetal compromise. The priority intervention is to immediately discontinue oxytocin, as it is the causative agent stimulating excessive uterine activity. Stopping the infusion reduces uterine contractions and improves uteroplacental perfusion. Other interventions, such as repositioning, oxygen administration, or tocolytics, may follow if fetal status does not improve after oxytocin is stopped.
Correct Answer Is:
D. Discontinue the oxytocin IV infusion.
6.

A nurse is caring for a client who is in labor and reports having difficulty voiding. Which of the following actions should the nurse take?

  • A. Help the client recline their back against the bed at a 45° angle.
  • B. Have the client sip warm water through a straw.
  • C. Use a squeeze bottle to pour warm water over the client's perineum.
  • D. Place the client in a left lateral position.

Explanation

Explanation
Pouring warm water over the perineum helps stimulate the micturition reflex and relaxes the perineal muscles, making it easier for the client to void. During labor, bladder distention can interfere with fetal descent and increase discomfort, so facilitating urination is important. This noninvasive intervention is commonly effective and promotes bladder emptying without altering labor progression.
Correct Answer Is:
C. Use a squeeze bottle to pour warm water over the client's perineum.
7.

A nurse is teaching about car seat safety to the parents of a newborn who was delivered at 38 weeks of gestation. Which of the following statements by a parent indicates an understanding of the teaching?

  • A. “When my baby is 1 year old, I can turn their car seat facing forward.”
  • B. “My baby will need a car seat challenge test before discharge.”
  • C. “I can use a sleep sack to keep my baby warm in the car seat.”
  • D. “The car seat should be positioned in the car at a 45-degree angle.”

Explanation

Explanation
Newborn car seats should be installed at approximately a 45-degree angle to keep the infant’s airway open and reduce the risk of airway obstruction. This angle helps prevent the newborn’s head from falling forward, which could compromise breathing. Proper positioning is essential for safety during travel, especially in infants with limited head and neck control.
Correct Answer Is:
D. “The car seat should be positioned in the car at a 45-degree angle.”
8.

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?

  • A. Urinary output
  • B. Respiratory status
  • C. Heart rate
  • D. 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.
9.

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.)

  • A. Exaggerated Moro reflex
  • B. Acrocyanosis
  • C. Tachypnea
  • D. Shrill pitched cry
  • E. 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.
10.

A nurse is caring for a client who is receiving terbutaline to treat preterm labor. Which of the following findings should the nurse identify as a potential adverse effect of this medication?

  • A. Bradycardia
  • B. Shortness of breath
  • C. Hot flashes
  • D. Heart palpitations

Explanation

Explanation
Terbutaline is a beta-adrenergic agonist used as a tocolytic to suppress uterine contractions. Because it stimulates beta-1 and beta-2 receptors, common adverse effects include tachycardia, heart palpitations, tremors, nervousness, and hyperglycemia. Palpitations occur due to increased heart rate and myocardial stimulation and should be closely monitored, as excessive cardiovascular effects may require discontinuation of the medication.
Correct Answer Is:
D. Heart palpitations.

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