ATI Maternal Newborn Proctored Exam 2024

ATI Maternal Newborn Proctored Exam 2024 Related

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4 minutes after the birth of the baby there is a sudden gush of blood from the mom's vagina and the about 8 inches of umbilical cord slides out. What action should nurse take first?

  • A. Watch for emergence of placenta
  • B. Assess for signs of uterine inversion
  • C. Perform fundal massage
  • D. Prepare for possible episiotomy repair
Correct Answer: A

Rationale: In this situation, the nurse should first watch for the emergence of the placenta. This is because the gush of blood followed by the umbilical cord slipping out indicates a possible placental abruption, where the placenta separates from the uterine wall before the baby is born. It is crucial to closely monitor the situation for signs of an incomplete placental delivery or any further complications. If the placenta does not deliver within a reasonable timeframe or if there are signs of excessive bleeding or other issues, immediate medical intervention may be necessary.

You may also like to solve these questions

What is the priority nursing action for a newborn with a temperature of 35.5°C (95.9°F)?

  • A. Place the newborn under a radiant warmer
  • B. Administer warm IV fluids
  • C. Swaddle the newborn in warm blankets
  • D. Provide glucose supplementation
Correct Answer: A

Rationale: Placing the newborn under a radiant warmer helps raise body temperature and prevent complications.

What blood test is important for potential blood type incompatibility issues during pregnancy?

  • A. complete blood count (CBC)
  • B. blood glucose
  • C. blood type and Rh factor
  • D. blood lipid profile
Correct Answer: C

Rationale:

A mother's laboratory results indicate the presence of cocaine and alcohol. The characteristic in her newborn that would indicate to the nurse that the baby has been affected with fetal alcohol syndrome would be:

  • A. Cleft lip
  • B. Polydactyly
  • C. Umbilical Hernia
  • D. Small upturned nose neonate weighs 3.2 kg, The health care provider prescribes the following orders for the neonate and signs the order sheet. Which order would the nurse question? Progress Notes: 12/01/22- 10am ï‚· Acetaminophen (Tylenol) 10mg/kg per rectum every 4-6 hours prn for pain ï‚· Ampicillin 200mg/kg IV every 6 hours in D5.45 NSSIV @ 125ml/hr. ï‚· Mom may breastfeed ad lib ï‚· Draw blood cultures x 3 in A.M. ï‚· Urine C&S in A.M.
Correct Answer: D

Rationale: The order that the nurse should question is "Ampicillin 200mg./kg IV every 6 hours." The usual dosage for ampicillin is 200-300 mg/kg/day divided into 4-6 doses, not every 6 hours. Administering ampicillin every 6 hours at 200mg/kg could potentially lead to overdose for the neonate. It is important to clarify this dosage with the health care provider before administering the medication to ensure the safety of the newborn.

A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?

  • A. Vomiting
  • B. Tachycardia
  • C. Respiratory depression
  • D. Hypotension
Correct Answer: D

Rationale: Epidural anesthesia can cause hypotension as a common complication. This occurs because the local anesthetic affects the sympathetic nerves, leading to vasodilation and subsequent lowering of blood pressure. It is crucial for nurses to monitor the client's blood pressure closely and be prepared to administer IV fluids or medications to address the hypotension promptly. Vomiting, tachycardia, and respiratory depression are not typically associated with epidural anesthesia; therefore, hypotension is the most likely complication to be identified in this scenario.

The nurse is assessing a client who reports vaginal bleeding at 20 weeks' gestation. What is the priority action?

  • A. Assess the amount and color of bleeding.
  • B. Place the client in a Trendelenburg position.
  • C. Administer Rho(D) immune globulin.
  • D. Perform a vaginal examination.
Correct Answer: A

Rationale: Assessing the bleeding provides critical information to determine the next steps and evaluate potential complications.

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