ATI RN
RN Maternal Nursing OB Newborn 2023 2024 Exam Questions
Extract:
A nurse is caring for a client who is in labor.
Exhibit1
Nurses' Notes
0900:
Contractions occurring every 3 to 4 min, lasting 80 to 90
seconds. Client rates pain with contractions as 10 on a scale of 0
to 10 and requests an epidural. Contractions approximately 4
min apart. Vaginal examination reveals cervix dilated 5 cm. 80%
effaced, -1 station, vertex presentation. FHR baseline 142/min
with moderate variability. IV fluid bolus initiated.
0930:
Epidural inserted by anesthesiology. Client reports pain as 2 on
a scale of 0 to 10.
0950.
Spontaneous rupture of membranes with clear fluid
1000:
Variable decelerations noted on the electronic fetal heart rate
monitor tracing, FHR baseline 140/min. Deceleration 90/min,
lasting 30 seconds. Loop of umbilical cord visible at vaginal introitus
Question 1 of 5
Select the 5 actions the nurse should take
Correct Answer: A,B,C,D,F
Rationale: A prolapsed umbilical cord is a life-threatening emergency requiring immediate intervention to relieve cord compression and restore fetal oxygenation. The priority actions are:
Notify the provider
Reposition the client (Trendelenburg or knee-chest)
Manually relieve pressure on the cord
Administer oxygen
Increase IV fluids for better circulation
Extract:
A nurse on a postpartum unit is caring for a client.
Exhibit 1
Vital Signs
Postpartum Day 3, 0815:
Temperature 38.2° C (100.8° F)
Heart rate 104/min|
Respiratory rate 18/min
BP 108/70 mm Hg
SaO2, 979 on room air
Question 2 of 5
For each finding, click to specity if the finding increases the client's risk for uterine atony or infection.
| finding | Uterine Atony | Infection |
|---|---|---|
| Prenatal anemia | ||
| High parity | ||
| Prolonged rupture of membranes | ||
| Cesarean birth | ||
| Polyhydramnios |
Correct Answer:
Rationale:
Extract:
The nurse continues to care for the client who is at 30 weeks of
gestation.
Exhiont 2
Vital Signs
1000:
Temperature 37.4"C（99.3*F)
Heart rate 90/min
Respiratory rate 20/min
Blood pressure 148/94 mm Hg
Oxygen saturation 95% on room air
1100:
Temperature 37° C (98.6° F)
Heart rate 92/min
Respiratory rate 24/min
Blood pressure 156/96 mm Hg
Oxygen saturation 94% on room air
1400:
Temperature 37.2°C（98.9*F）
Heart rate 80/min
Respiratory rate 14/min
Blood pressure 170/112 mm Hg
oxygen saturation 92% on room air
Question 3 of 5
Complete the following sentence by using the list of options. Based on the client findings, the nurse should first admister-----------------and then prepare to administer-----------------------
Correct Answer: B,A
Rationale:
Rationale:
First administer hydralazine ✅
The client is experiencing severe hypertension (BP 170/112 mm Hg at 1400), which indicates preeclampsia with severe features.
Hydralazine is a fast-acting antihypertensive that helps lower blood pressure and reduce the risk of stroke, placental abruption, or fetal compromise.
Then prepare to administer calcium gluconate ✅
If the client is receiving magnesium sulfate for seizure prevention (common in severe preeclampsia), calcium gluconate is the antidote in case of magnesium toxicity (which can cause respiratory depression or cardiac arrest).
The nurse should have calcium gluconate readily available in case of toxicity signs like loss of deep tendon reflexes, respiratory depression, or cardiac arrhythmias.
Notify the provider 🚨
The severely elevated BP (170/112 mm Hg) and potential risk for eclampsia (seizures) require immediate provider notification for further management.
Extract:
The nurse continues to care for the client who is at 30 weeks or
gestation.
Exhibit 2
Assessment
1000:
Client is Gravida 1 Para 0 and reports headache, nausea.
vomiting, and right upper abdominal pain.
Client is alert and oriented, appears restless. Client has gained
0.68 kg (1.5 lb) within the last week. Slight facial edema is
present. Heart rate regular and without murmur. Respirations
even, non-labored. Lungs clear to auscultation. Abdomen
gravid. Fundal height measurement 29 cm. 1+ dependent
edema noted bilaterally. Deep tendon reflex (DTR) is 3+
bilaterally.
Applied external fetal heart monitor. No contractions noted.
Fetal heart rate 140/min.
Question 4 of 5
Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.
Correct Answer: A,C,G
Rationale: Reposition the client (Trendelenburg or knee-chest)
Extract:
The nurse continues to care for the client who is at 30 weeks or
gestation. Exhibit1: Vital Signs
1000:
Temperature 37.4° C (99.3° F)
Heart rate 90/min|
Respiratory rate 20/min
Blood pressure 148/94 mm Hg
Oxygen saturation 95% on room air
Exhibit 2
Assessment
1000:
Client is Gravida 1 Para 0 and reports headache, nausea.
vomiting, and right upper abdominal pain.
Client is alert and oriented, appears restless. Client has gained
0.68 kg (1.5 lb) within the last week. Slight facial edema is
present. Heart rate regular and without murmur. Respirations
even, non-labored. Lungs clear to auscultation. Abdomen
gravid. Fundal height measurement 29 cm. 1+ dependent
edema noted bilaterally. Deep tendon reflex (DTR) is 3+
bilaterally.
Applied external fetal heart monitor. No contractions noted.
Fetal heart rate 140/min.
Question 5 of 5
Select the 5 findings that require follow-up by the nurse.
Correct Answer: A,C,D,E,G
Rationale: Administer oxygen