ATI RN
foundation of nursing questions and answers Questions
Question 1 of 5
Which intrapartal assessment should be avoided when caring for a patient with HELLP syndrome?
Correct Answer: A
Rationale: The correct answer is A: Abdominal palpation. Palpating the abdomen can potentially cause rupture of the liver in patients with HELLP syndrome due to increased risk of liver hematoma. This can lead to severe bleeding and compromise the patient's condition. Checking deep tendon reflexes (
C), auscultation of the heart and lungs (
D), and venous sample of blood (
B) are safe assessments that do not pose a risk of exacerbating the patient's condition. It is crucial to prioritize patient safety and avoid interventions that can harm the patient, making avoiding abdominal palpation the correct choice in caring for a patient with HELLP syndrome.
Question 2 of 5
Which finding would indicate concealed hemorrhage in abruptio placentae?
Correct Answer: B
Rationale: The correct answer is B: Hard boardlike abdomen. In abruptio placentae, concealed hemorrhage can lead to blood accumulating behind the placenta, causing the uterus to become tense and rigid, resulting in a hard boardlike abdomen. This finding indicates significant internal bleeding and requires immediate medical attention.
Rationale:
A: Bradycardia is a slow heart rate and is not typically associated with concealed hemorrhage in abruptio placentae.
C: Decrease in fundal height may indicate intrauterine growth restriction, not specifically concealed hemorrhage.
D: Decrease in abdominal pain is not a typical indicator of concealed hemorrhage; in fact, pain may increase due to the increased pressure in the uterus from the bleeding.
Question 3 of 5
Which finding on a prenatal visit at 10 weeks might suggest a hydatidiform mole?
Correct Answer: C
Rationale: The correct answer is C: Fundal height measurement of 18 cm. This finding suggests a hydatidiform mole because it is larger than expected for a 10-week pregnancy due to excessive trophoblastic proliferation. A: Blood pressure is within normal range. B: Nausea is common in early pregnancy and not specific to a mole. D: History of bright red spotting is more indicative of a miscarriage or other complications, not necessarily a mole.
Question 4 of 5
A patient who was pregnant had a spontaneous abortion at approximately 4 weeks’ gestation. At the time of the miscarriage, it was thought that all products of conception were expelled. Two weeks later, the patient presents at the clinic office complaining of “crampy” abdominal pain and a scant amount of serosanguineous vaginal drainage with a slight odor. The pregnancy test is negative. Vital signs reveal a temperature of 100F, with blood pressure of 100/60 mm Hg, irregular pulse 88 beats/minute (bpm), and respirations, 20 breaths per minute. Based on this assessment data, what does the nurse anticipate as a clinical diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Uterine infection. The patient's symptoms of crampy abdominal pain, scant serosanguineous vaginal drainage with odor, negative pregnancy test, and vital signs indicating fever, low blood pressure, and irregular pulse suggest an infection. The history of recent miscarriage raises suspicion for retained products of conception leading to infection. Ectopic pregnancy (choice
A) would present with different symptoms such as abdominal pain, vaginal bleeding, and positive pregnancy test. Gestational trophoblastic disease (choice
C) typically presents with abnormal vaginal bleeding and high levels of hCG. Endometriosis (choice
D) is a chronic condition and not related to the acute symptoms described. In summary, the clinical presentation aligns with uterine infection given the patient's history, symptoms, and vital signs.
Question 5 of 5
Which finding in the assessment of a patient following an abruption placenta could indicate a major complication?
Correct Answer: C
Rationale: The correct answer is C - bleeding at IV insertion site. This finding could indicate a major complication following an abruption placenta, such as disseminated intravascular coagulation (DI
C) or hypovolemic shock. Bleeding at the IV site suggests a systemic issue affecting the patient's coagulation status.
Choices A, B, and D are not directly indicative of a major complication following an abruption placenta. Urine output, blood pressure, and respiratory rate are important parameters to monitor but do not specifically point to a major complication in this context.