ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 of 5
A nurse is assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect?
Correct Answer: C
Rationale: The correct answer is C: Uterine tenderness. Endometritis is an infection of the uterine lining, which causes inflammation and tenderness in the uterus. This finding is expected in a client with endometritis.
A: Temperature of 37.4°C is within normal range postpartum and not specific to endometritis.
B: WBC count of 9,000/mm3 is within normal range and may not be significantly elevated in endometritis.
D: Scant lochia may not be a specific finding for endometritis as lochia changes can vary postpartum.
Question 2 of 5
A nurse is admitting a client to the birthing unit who reports her contractions started 1 hr ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions?
Correct Answer: D
Rationale: The correct answer is D: Postpartum hemorrhage. The client being 80% effaced and 8 cm dilated indicates she is in active labor, not at risk for ectopic pregnancy (
A). Hyperemesis gravidarum (
B) is severe nausea and vomiting during pregnancy, unrelated to cervical dilation. Incompetent cervix (
C) is characterized by painless cervical dilation in the second trimester. Postpartum hemorrhage (
D) is a risk due to the advanced cervical dilation and effacement, making it more likely for excessive bleeding during and after delivery.
Question 3 of 5
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?
Correct Answer: D
Rationale: The correct answer is D: Assist the client in pulling their knees toward their abdomen. In shoulder dystocia, the McRoberts maneuver involves hyperflexing the mother's legs against her abdomen to help dislodge the impacted shoulder. This action widens the pelvic outlet, allowing for easier delivery of the baby. Applying pressure to the fundus (
A) does not address the shoulder dystocia. Pressing firmly on the suprapubic area (
B) may not be effective in resolving the shoulder dystocia. Moving the client onto their hands and knees (
C) may not provide the optimal position for resolving the shoulder dystocia.
Therefore, assisting the client in pulling their knees toward their abdomen (
D) is the most appropriate action to help alleviate the shoulder dystocia and facilitate the delivery of the baby.
Question 4 of 5
A nurse is assessing a client who is 1 hr postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct action for the nurse to take first in this situation is to massage the client's fundus. This is because excessive vaginal bleeding postpartum can indicate uterine atony, which is the most common cause of postpartum hemorrhage. Massaging the fundus helps stimulate uterine contractions, which will help to control the bleeding. It is important to address this issue promptly to prevent further complications. Administering oxytocin (choice
B) can also help with uterine contractions, but massaging the fundus should be done first. Emptying the client's bladder (choice
C) can relieve pressure on the uterus, but it is not the priority in this situation. Providing oxygen (choice
D) is not necessary unless the client is showing signs of hypoxia, which is not indicated in the scenario.
Question 5 of 5
A nurse is caring for a client who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following actions should the nurse take next?
Correct Answer: B
Rationale: The correct answer is B: Cover the umbilical cord with a sterile saline-saturated towel. This action is essential to prevent compression and drying of the umbilical cord, which could lead to fetal hypoxia and compromise fetal circulation. By covering the umbilical cord with a sterile saline-saturated towel, the nurse can protect the cord and maintain fetal perfusion until delivery can be expedited. Performing a vaginal examination (choice
A) could further compress the cord and worsen the situation. Administering oxygen (choice
C) may be beneficial but is not the priority in this urgent situation. Initiating IV fluids (choice
D) is not the immediate priority when fetal bradycardia and umbilical cord prolapse are present.