ATI RN
ATI RN Maternal Newborn Latest Update. Questions
Extract:
Question 1 of 5
A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?
Correct Answer: A
Rationale: The correct answer is A: Single palmar creases (p200Down Syndrome). This is an important finding as it can indicate the presence of Down Syndrome in the newborn. It is important to report this to the provider promptly for further evaluation and management. Single palmar creases are not typically seen in healthy newborns.
Rust-stained urine (choice
B) is likely due to urate crystals, which can be a normal finding in newborns and usually resolves on its own. Transient circumoral cyanosis (choice
C) is common in newborns due to immature circulation and usually resolves without intervention. Subconjunctival hemorrhage (choice
D) is also a common benign finding in newborns and usually resolves without treatment.
Question 2 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 characterized by inflammation of the inner lining of the uterus, which results in uterine tenderness. This finding is significant in postpartum clients as it indicates an infection in the uterus. A: Temperature within normal range is not a specific indicator of endometritis. B: WBC count within normal limits is not a specific indicator of endometritis. D: Scant lochia may be present in postpartum clients without endometritis.
Question 3 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, which increases the risk of postpartum hemorrhage due to the rapid dilation of the cervix. As the cervix dilates, the blood vessels in the area are more prone to bleeding post-delivery. Ectopic pregnancy (
A) occurs when the fertilized egg implants outside the uterus, which is not relevant in this scenario. Hyperemesis gravidarum (
B) is severe nausea and vomiting during pregnancy, unrelated to the client's current condition. Incompetent cervix (
C) is a condition where the cervix opens prematurely, typically in the second trimester, not during active labor.
Question 4 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 to rotate the pelvis, allowing the baby's shoulder to dislodge. This action enlarges the pelvic outlet, facilitating the delivery of the baby. Applying pressure to the fundus (
A) or pressing on the suprapubic area (
B) are not appropriate interventions for shoulder dystocia. Moving the client onto their hands and knees (
C) may be helpful in some cases but is not the initial step for the McRoberts maneuver.
Question 5 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 is to massage the client's fundus. This is because excessive vaginal bleeding postpartum can indicate uterine atony, which is a common cause of postpartum hemorrhage. By massaging the fundus, the nurse can help the uterus contract and prevent further bleeding. This intervention is crucial in managing postpartum hemorrhage. Administering oxytocin (choice
B) can help with uterine contractions, but massaging the fundus should be done first. Emptying the client's bladder (choice
C) is important to prevent uterine atony, but it is not the first priority in this situation. Providing oxygen (choice
D) is not directly related to managing postpartum bleeding and should not be the first action.