ATI Maternity Nur230

Extract:

Pregnant client

Question 1 of 5

A nurse is caring for a pregnant client and reviewing signs of complications that should be promptly reported to the provider. Which of the following should be included?

A. Vaginal bleeding.B. Lightheadedness when lying on back.C. Heartburn after eating.D. Swelling of the ankles.

Correct Answer: A

Rationale: Vaginal bleeding during pregnancy can indicate serious complications like placenta previa or placental abruption, requiring immediate reporting to the healthcare provider.

Extract:

Adolescent who is postoperative following scoliosis repair with Harrington rod instrumentation

Question 2 of 5

A nurse is planning care for an adolescent who is postoperative following scoliosis repair with Harrington rod instrumentation. Which of the following interventions should the nurse include in the plan of care?

A. Keep the head of the bed at a 30-degree angle.B. Initiate the use of a PCA pump for pain control.C. Reposition the client by log rolling every 4 hours.D. Place the client in protective isolation.

Correct Answer: B

Rationale: A PCA pump allows for effective, individualized pain control post-scoliosis surgery, which is critical for patient comfort and recovery.

Extract:

Multiple clients on the postpartum unit

Question 3 of 5

A nurse is providing care to multiple clients on the postpartum unit. Which of the following clients is at the greatest risk for developing a puerperal infection?

A. A client who has a cesarean incision that is well-approximated with no drainage.B. A client who does not wash her hands between perineal care and breastfeeding.C. A client who has an episiotomy that is erythematous and has extended into a third-degree laceration.D. A client who is not breastfeeding and is using measures to suppress lactation.

Correct Answer: C

Rationale: An erythematous episiotomy extended to a third-degree laceration increases infection risk due to the deeper tissue involvement and potential for bacterial growth.

Extract:

Primigravida at 42 weeks of gestation who believes she is in labor

Question 4 of 5

A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor?

A. Cervical dilation.B. Report of pain above the umbilicus.C. Brownish vaginal discharge.D. Amniotic fluid in the vaginal vault.

Correct Answer: A

Rationale: Cervical dilation is a definitive sign of labor progression, confirming the onset of labor.

Extract:

Client for a local health fair about breast self-examination (BSE)

Question 5 of 5

A community health nurse is developing a pamphlet about breast self-examination (BSE) for a local health fair. Which of the following instructions should the nurse include?

A. Expect some breast dimpling or discharge with age.B. Using the palm of the hand, feel for lumps using a circular motion.C. Breasts can be examined in the shower with soapy hands.D. For those who have a menstrual cycle, perform a BSE every month, 2 or 3 days before menstruation.

Correct Answer: C

Rationale: Examining breasts in the shower with soapy hands facilitates smooth gliding of fingers, making it easier to detect lumps or changes.

ATI Maternity Nur230 | Nurselytic

Nurselytic

ATI RN

ATI RN