ATI Maternal Newborn Proctored Exam

ATI Maternal Newborn Proctored Exam Related

Review ATI Maternal Newborn Proctored Exam related questions and content

A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?

  • A. Provide a stimulating environment
  • B. Monitor blood glucose level every hr.
  • C. Initiate seizure precautions.
  • D. Place the infants on his back with legs extended.
Correct Answer: C

Rationale: Neonatal abstinence syndrome (NAS) occurs in infants who are exposed to addictive substances in utero, typically opioids. The signs of NAS can include irritability, tremors, feeding difficulties, and seizures. Therefore, it is essential for the nurse to initiate seizure precautions when caring for an infant with signs of NAS. This includes ensuring a safe environment, padding the crib, monitoring closely for seizure activity, and having emergency medications readily available if needed. Providing a stimulative environment (Option A) would be inappropriate as it can exacerbate symptoms of NAS. While monitoring blood glucose (Option B) is important in some situations, such as for infants of diabetic mothers, it is not the priority in NAS. Placing the infant on their back with legs extended (Option D) does not directly address the immediate concerns related to NAS.

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A nurse is caring for a client who is 1 day postpartum and is taking a sitz bath. To determine the client's tolerance of the procedure, which of the following assessments should the nurse perform?

  • A. Bladder distention
  • B. Pulse rate
  • C. Respiratory rate
  • D. Color of lochia
Correct Answer: B

Rationale: The nurse should assess the client's pulse rate to determine the client's tolerance of the sitz bath. An elevated pulse may indicate that the sitz bath is causing discomfort or stress to the client. Monitoring the pulse rate is essential to ensure the client's safety and comfort during the procedure. Bladder distention, respiratory rate, and color of lochia are important assessments in postpartum care but are not specifically related to determining the client's tolerance of a sitz bath.

The APGAR is performed at what minutes?

  • A. 1 and 5
  • B. 2 and 4
  • C. 5 and 10
  • D. At birth and 5 minutes
Correct Answer: A

Rationale: The APGAR score is a quick assessment tool used to evaluate a newborn's health and overall condition immediately after birth and again at 5 minutes after birth. The five categories evaluated in the APGAR score are Appearance, Pulse, Grimace, Activity, and Respiration. The assessment is typically done at 1 minute and 5 minutes after birth to quickly determine if the baby needs any immediate medical attention or interventions. The scores at both time points provide valuable information about the baby's well-being and can guide healthcare providers in deciding on appropriate next steps for care.

On examination the hands and feet of a 6 hours old infant is cyanotic without signs of distress. The nurse should document these findings as:

  • A. Potential for respiratory distress
  • B. Poor oxygenation
  • C. Cold stress
  • D. Acrocyanosis
Correct Answer: D

Rationale: Acrocyanosis is a condition commonly seen in newborns where the hands and feet appear blue or purple in color due to decreased circulation in the peripheral blood vessels. It is usually a normal finding in newborns and is not associated with distress or poor oxygenation. Unlike central cyanosis which indicates a more serious underlying issue affecting oxygen levels in the blood, acrocyanosis is a benign and self-limiting condition. It is important for the nurse to recognize and document acrocyanosis to differentiate it from other potentially concerning conditions.

The nurse is monitoring a client with severe preeclampsia. What assessment finding indicates worsening condition?

  • A. Proteinuria of +1.
  • B. Respiratory rate of 16 breaths per minute.
  • C. New-onset confusion and restlessness.
  • D. Urine output of 40 mL/hr.
Correct Answer: C

Rationale: New-onset confusion and restlessness may indicate cerebral edema or impending eclampsia.

What is the most appropriate action for a nurse when a newborn has jaundice on the second day of life?

  • A. Increase fluid intake of the mother
  • B. Phototherapy
  • C. Monitor bilirubin levels
  • D. Refer to a pediatric specialist
Correct Answer: B

Rationale: Phototherapy helps treat jaundice by breaking down bilirubin.

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