ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
A nurse is caring for a client who is experiencing a postpartum hemorrhage and has a new prescription for misoprostol.
Exhibit 2: Medical History
Preeclampsia
Cesarean birth of viable twin male newborns
Question 1 of 5
The nurse is assessing the client 30 min later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
| Findings 30 min later | Unrelated to diagnosis | Indication Of potential improvement | Indication of Potential worsening condition |
|---|---|---|---|
| Fundus at level of umbilicus | |||
| Cloudy urine | |||
| Blood pressure 80/50 mm Hg | |||
| Moderate lochia rubra | |||
| Thready pulse | |||
| Fundus firm to palpation |
Correct Answer:
Rationale:
Correct
Answer:
Rationale:
- Fundus at the level of the umbilicus is an indication of potential improvement as it indicates proper involution of the uterus.
- Cloudy urine is unrelated to the diagnosis and may indicate other issues like urinary tract infection.
- Blood pressure of 80/50 mm Hg is an indication of potential worsening condition as it is hypotensive.
- Moderate lochia rubra is also an indication of potential worsening condition as it may indicate excessive bleeding.
- Thready pulse is unrelated to the diagnosis.
- Fundus firm to palpation is an indication of potential improvement as it indicates proper uterine contraction and involution.
Extract:
A nurse is assessing a postpartum client during a follow-up visit.
Exhibit 3 - Vital Signs
Time Vital Signs
0930 Temperature 37°C (98.6°F)
Pulse rate 78/min
Respiratory rate 12/min
Blood pressure 124/80 mm Hg
Pulse oximetry 100%
Question 2 of 5
The nurse is teaching the client about postpartum depression. The nurse should encourage the client to----------------- and ----------------- to help prevent postpartum depression.
Correct Answer: B,E
Rationale: The correct answers are B and E. Maintaining a strong support system is crucial for emotional well-being, as it provides the client with reassurance, understanding, and help in times of need. This can help prevent feelings of isolation and loneliness, common in postpartum depression. Additionally, exercising for at least 30 minutes per day can release endorphins, improve mood, and reduce stress, all of which can contribute to preventing postpartum depression.
Choices A, C, and D are important for overall health but do not specifically address the emotional and mental aspects that can lead to postpartum depression.
Extract:
A nurse is assessing a postpartum client who delivered vaginally 8 hr ago.
Exhibit 1 - Nurses' Notes: 0700
Breasts soft, nipples intact. Uterus palpated firm, midline, and at the level of the umbilicus.
Moderate amount of lochia rubra. Episiotomy site well approximated with mild edema and
ecchymosis. Client reports pain as 2 on a scale of 0 to 10. Able to void spontaneously; no bladder
distention. Deep tendon reflexes 1+. Peripheral edema 2+ in bilateral lower extremities.
Exhibit 2 - Nurses' Notes: 1100
Breasts soft, nipples intact. Uterus palpated soft with lateral deviation and 1 cm above the
umbilicus. Large amount of lochia rubra. Episiotomy site well approximated with mild edema
and ecchymosis. Client reports pain as 3 on a scale of 0 to 10. Deep tendon reflexes 1+.
Peripheral edema 2+ in bilateral lower extremities.
Question 3 of 5
Select the 3 findings that require immediate follow-up.
Correct Answer: A,B,C
Rationale: The correct choices for immediate follow-up are A, B, and C. A lateral deviation of the uterus could indicate a potential complication like uterine prolapse. Deep tendon reflexes 1+ could suggest a neurological issue or electrolyte imbalance. A pain rating of 3 on a scale of 0 to 10 (increased) requires further assessment to determine the cause and provide appropriate treatment.
Choices D, E, F, and G are not as urgent. Peripheral edema 2+ bilateral lower extremities could be indicative of fluid retention, which may need monitoring but not immediate intervention. Soft uterine tone may be expected postpartum, and a large amount of lochia rubra could be normal after birth. A blood pressure of 136/86 mm Hg is slightly elevated but not critically high, so it may require monitoring but not immediate follow-up.
Extract:
Question 4 of 5
A nurse is caring for a client who is receiving an epidural block with an opioid analgesic. The nurse should monitor for which of the following findings as an adverse effect of the medication?
Correct Answer: C
Rationale: The correct answer is C: Hypotension. Opioid analgesics can cause vasodilation, leading to a drop in blood pressure. The nurse should monitor for hypotension as a potential adverse effect, as this can result in dizziness and decreased perfusion. Hyperglycemia (
A) is not typically associated with opioid analgesics. Bilateral crackles (
B) are more indicative of fluid overload or pulmonary edema. Polyuria (
D) is excessive urination and is not a common adverse effect of opioid analgesics.
Question 5 of 5
A nurse is providing teaching to a client who is at 35 weeks of gestation and has a prescription for an amniocentesis. Which of the following client statements indicates an understanding of the teaching?
Correct Answer: A
Rationale: The correct answer is A: "I should empty my bladder before the procedure." This statement indicates understanding because a full bladder can obstruct visualization during the amniocentesis.
Choice B is incorrect because the client should be lying flat on their back during the procedure.
Choice C is incorrect as local anesthesia is typically used, and the client is awake.
Choice D is incorrect as fasting is not required for an amniocentesis.