ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
A nurse in a clinic is caring for a 16-year-old adolescent.
Provider Prescriptions
1300:
Standing prescriptions for clients who present with abdominal pain:
Obtain laboratory tests:
Urinalysis
Cervical culture
C-reactive protein
Beta hCG
Question 1 of 5
Which of the following findings should the nurse report to the provider? (Select all that apply.)
Correct Answer: A,B,D,E,F
Rationale: The correct findings to report to the provider are A, B, D, E, and F. A - Abdominal assessment is crucial as it can indicate underlying issues. B - Vaginal discharge can be a sign of infection or other gynecological problems. D - Temperature abnormalities can signal infection or systemic issues. E - Dyspareunia (painful intercourse) may indicate underlying conditions. F - Condom usage is important for assessing safe sex practices. These findings are relevant for the provider to assess and potentially address any health concerns.
Extract:
A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hr old.
Physical Examination:
• Fontanels soft and flat
• Head molded with caput succedaneum
• Eyes symmetric, no discharge, sclera yellow
• Mucous membranes dry
• Abdomen soft and rounded, bowel sounds present x 4 quadrants
Question 2 of 5
Which of the following findings should the nurse report to the provider? (Select all that apply.)
Correct Answer: A,B,C,G
Rationale: The correct answers to report to the provider are A, B, C, and G. A Coombs test result should be reported as it indicates potential hemolytic anemia. Mucous membrane assessment is crucial for hydration status and oxygenation. Intake and output levels are key indicators of kidney function and hydration status. Sclera color can indicate liver function or anemia.
Choices D, E, and F are important assessments but do not typically require immediate reporting unless they are outside of normal ranges and affecting the patient's condition.
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 3 of 5
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:
- Hematuria and Proteinuria 2+ are signs of potential worsening conditions that the nurse should interpret as concerning findings.
- Positive clonus is a sign of potential improvement, indicating a positive response to treatment.
- Leukorrhea is unrelated to the diagnosis and should not be a focus of interpretation after 24 hours.
- BUN 40 mg/dL and Platelet count 110,000/mm3 are not provided in the question and thus cannot be interpreted.
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 4 of 5
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 (Findings 24 hr later): Deep vein thrombosis can lead to increased warmth in the affected extremity due to inflammation.
2. Tachycardia (Indication of worsening condition): Tachycardia can indicate worsening condition or potential complications such as pulmonary embolism.
3. Leukocytosis (Indication of improving condition): Leukocytosis can indicate the body's response to infection or inflammation, which may be improving.
Other
Choices:
D: Scant lochia rubra - Not relevant to the assessment of deep vein thrombosis.
E: Decreased extremity edema - Edema is not a typical finding associated with deep vein thrombosis.
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 5 of 5
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: [1, 0, 1]
The correct answers are A and C (Weigh perineal pads).
- A large bore IV catheter may be necessary for rapid fluid resuscitation in emergencies, indicated for critically ill patients.
- Weighing perineal pads is essential to monitor postpartum bleeding, ensuring accurate assessment and timely intervention.
- Assessing cervical dilation (
B) is not typically a nursing action but a medical provider's task during labor.
- Administering methotrexate (
D) is a medical intervention for conditions like ectopic pregnancy, not within a nurse's scope.