ATI RN
ATI RN Maternal Newborn Latest Update. Questions
Extract:
A nurse is caring for a client who is at 33 weeks of gestation.
Diagnostic Results:
• Proteinuria 3+, straw-colored urine
• Platelet count 150,000/mm3 (150,000 to 400,000/mm3)
• BUN 18 mg/dL (10 to 20 mg/dL)
Question 1 of 4
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
| Findings 24 hr later | Sign of potential worsening condition | Sign of potential improvement | Unrelated to diagnosis |
|---|---|---|---|
| Hematuria | |||
| Proteinuria 2+ | |||
| Leukorrhea | |||
| Positive clonus | |||
| BUN 40 mg/dL | |||
| Platelet count 110,000/mm3 |
Correct Answer:
Rationale:
Correct
Answer:
Rationale: The correct interpretation is Hematuria. Hematuria (blood in urine) can be a sign of potential worsening condition, requiring further investigation. Proteinuria 2+, Leukorrhea, Positive clonus, BUN of 40 mg/dL, and Platelet count of 110,000/mm3 are not specifically related to the findings 24 hours later and do not provide direct information on the client's status. Hematuria should be a significant focus for further assessment.
Extract:
A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
Medical History:
• Gravida 2 Para 2
• Cesarean birth
• Deep vein thrombosis with previous pregnancy
• Preeclampsia
• BMI of 32
Question 2 of 4
A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
| Findings 24 hr later | Indication of worsening condition | Indication of improving condition |
|---|---|---|
| Increased warmth in the extremity | ||
| Tachycardia | ||
| Leukocytosis | ||
| Scant lochia rubra | ||
| Decreased extremity edema |
Correct Answer:
Rationale:
Correct
Answer:
Rationale:
1. Increased warmth in the extremity: This is a key finding in deep vein thrombosis indicating inflammation and potential clot progression.
2. Tachycardia: Indicative of the body's response to a clot, signifying a worsening condition.
3. Leukocytosis: Elevated white blood cell count suggests an inflammatory response, further confirming a worsening condition.
Summary:
- Scant lochia rubra: Not directly related to deep vein thrombosis, less relevant in this context.
- Decreased extremity edema: While it could indicate improvement, it is not specific to deep vein thrombosis and may not be a reliable indicator.
Extract:
“A nurse on an antepartum unit is caring for a client.
Exhibit1:
Nurses' Notes 0900:Client reports a small amount of bright red blood in their underwear upon
awakening. Client denies contractions or abdominal pain. External fetal monitor applied.
0930:Client passed large amount of bright red blood from vagina.
Denies pain Uterine tone soft and nontender to palpation.
contraction pattern, no contractions noted.
Fetal heart rate pattern: Fetal heart rate baseline 135/min.
Moderate variability. No decelerations noted.
Exhibit2:
Vital Signs 0900: Temperature 36.2°C (97.2° F) Pulse rate 78/min Respiratory rate 20/min Blood pressure
112/64 mm Hg Fetal heart rate 132/min Pulse rate 82/min Blood pressure 116/60 mm Hg Fetal heart
rate 160/min
Exhibit3:
Medical History. G4P3 30 weeks gestation Previous pregnancies delivered via cesarean section
Question 3 of 4
Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify it the intervention is indicated or contraindicated for the client.
| Potential Nursing Action | Indicated | Contraindicated | |
|---|---|---|---|
| Insert a large bore intravenous catheter. | |||
| Assess cervical dilation. | |||
| Weigh perineal pads. | |||
| Administer methotrexate. |
Correct Answer: A, C
Rationale: [, (0, 0, 0), (1, 0, 0), (0, 0, 1)]
Correct
Answer: A, C
Rationale:
A: Inserting a large bore intravenous catheter is indicated for quick and efficient fluid administration in emergencies or critical conditions.
C: Weighing perineal pads helps monitor postpartum hemorrhage accurately by assessing the amount of blood loss.
Assessing cervical dilation (
B) is not indicated unless specified for a specific medical condition. Administering methotrexate (
D) is contraindicated in pregnancy and certain medical conditions.
Extract:
A nurse is caring for a newborn.
Exhibit 1
Medical History
1600:
Apgar score 9 at 1 min and 9 at 5 min
Birth weight 4,706 g (10 lb 6 oz)
Gestational age 40 weeks
Difficult vaginal birth with shoulder dystocia. Exhibit 2
Nurses' Notes
1700:
Newborn is active and moves all extremities except for right arm. No spontaneous movement of
the right arm noted. Right arm remains at side during Moro reflex. Exhibit 3
Physical Examination
1830:
Absent Moro reflex noted in right arm.
Right shoulder and arm are internally rotated and adducted. Elbow extended. Forearm pronated
with wrist and fingers flexed. Diagnosis: Brachial plexus injury resulting in Erb-Duchenne (Erb's
palsy) paralysis.
Question 4 of 4
Which of the following actions should the nurse plan to implement? For each potential nursing action, click to specify if the intervention is indicated or contraindicated for the newborn.
Correct Answer:
Rationale:
Correct
Answer: B: Assess for grasp reflex in the affected extremity.
Rationale:
- Assessing for grasp reflex is indicated to evaluate neurologic function and muscle tone in the affected arm.
- This helps in determining the extent of impairment and guiding further interventions.
- Range of motion exercises (
A) may worsen the condition if performed too early.
- Immobilizing the arm (
C) may lead to joint stiffness and muscle atrophy.
- Limiting physical handling (
D) may hinder bonding and infant's development.
Extract:
A nurse in a clinic is caring for a 16-year-old adolescent.
Exhibit 1
History and Physical
Adolescent is sexually active with two current partners.
IUD in place
Reports not using condoms during sexual activity.
History of type 1 diabetes mellitus”
Question 5 of 4
Which of the following conditions should the nurse identify as being consistent with the adolescent's assessment findings? For each finding click to specify if the assessment findings are consistent with trichomoniasis, gonorrhea, or candidiasis. Each finding may support more than one disease process.
| Assessment Findings | Trichomoniasis | Gonorrhea | Candidiasis |
|---|---|---|---|
| Abdominal pain. | |||
| Greenish discharge. | |||
| Diabetes. | |||
| Pain on urination. | |||
| Absence of condom. |
Correct Answer: B, D
Rationale: The correct answer is B, D . Abdominal pain (
A) is not specific to any of the given conditions. Diabetes (
C) is not directly related to the assessment findings provided. Absence of condom (E) is not an assessment finding, but a behavior. Trichomoniasis is characterized by greenish discharge, and pain on urination can be a symptom of both gonorrhea and trichomoniasis.