ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 of 5
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?
Correct Answer: D
Rationale: The correct answer is D: Instruct the client to press the provided button each time fetal movement is detected. This action is essential during a nonstress test to monitor fetal heart rate and movement patterns. Pressing the button allows the nurse to correlate fetal movements with changes in the heart rate, providing valuable information about the fetal well-being. Maintaining the client NPO (Option
A) is not necessary for a nonstress test. Placing the client in a supine position (Option
B) can decrease blood flow to the fetus. Instructing the client to massage the abdomen (Option
C) may lead to inaccurate test results.
Question 2 of 5
A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Decreased platelet count. In ITP, there is a decrease in the number of platelets, leading to an increased risk of bleeding. Platelets are essential for blood clotting, so a decreased count can result in easy bruising, petechiae, and prolonged bleeding. The other choices are incorrect because in ITP, there is no significant increase in ESR, decrease in megakaryocytes (which are platelet precursors), or increase in WBC count. By understanding the pathophysiology of ITP and its effects on platelets, we can confidently select choice A as the expected finding in this scenario.
Question 3 of 5
A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?
Correct Answer: C
Rationale: The correct answer is C: Administer Rho(
D) immune globulin. This is the priority intervention following an amniocentesis in an Rh-negative client at 15 weeks gestation to prevent Rh isoimmunization. Administering Rho(
D) immune globulin helps prevent the mother's immune system from forming antibodies against Rh-positive fetal blood cells, which could lead to hemolytic disease in the newborn. Checking the client's temperature (
A) is not the priority as there is no immediate risk related to the procedure. Observing for uterine contractions (
B) is important but not the priority immediately post-procedure. Monitoring the FHR (
D) is important but not the priority at this time.
Question 4 of 5
A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow.
Correct Answer: A,B,CD
Rationale: The correct sequence for performing Leopold maneuvers is A, B, C, and D. Firstly, palpating the fundus to identify the fetal part helps determine the position of the baby in the uterus. Secondly, determining the location of the fetal back provides information on the baby's position relative to the mother's spine. Thirdly, palpating for the fetal part presenting at the inlet helps identify which part of the baby is entering the birth canal. Lastly, identifying the attitude of the head gives insight into how the baby is positioned within the pelvis for delivery. This sequential approach allows for a systematic assessment of fetal position and presentation. The other choices are incorrect as they do not follow the correct order of Leopold maneuvers, which can lead to inaccurate assessment and potential complications during labor and delivery.
Question 5 of 5
A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?
Correct Answer: A
Rationale: The correct answer is A: Oligohydramnios. Electronic fetal monitoring is used to assess fetal well-being by monitoring the baby's heart rate and uterine contractions. Oligohydramnios, which is low amniotic fluid levels, can indicate fetal distress and compromise, necessitating closer monitoring. Hyperemesis gravidarum (
B) is severe nausea and vomiting, not directly related to fetal monitoring. Leukorrhea (
C) is normal vaginal discharge during pregnancy and not a reason for fetal monitoring. Periodic tingling of the fingers (
D) is unrelated to fetal assessment.