ATI RN
ATI Nur 232 Maternity Final Exam SP24 Questions
Extract:
Nurse's Notes (0700hrs): Fetal heart tones (FHT): 145/min, Uterine contractions every 2 minutes, lasting 80 seconds, moderate intensity. Vital Signs (0700hrs): Client reports low back pain and frequent urination since last night. Urination is painful and only a small amount is passed each time. Abdomen is soft and nontender. Vaginal examination: 2 cm dilated, 100% effaced, 0 station. Bloody mucus noted on sterile glove. Medical History: G2P1, 34 weeks pregnant, No known allergies, Previous pregnancy was full-term with no complications. Diagnostic Results (0700hrs): Place client on electronic fetal monitor, Administer IV fluids, Monitor vital signs every hour, Notify provider of any changes in client status. A 28-year-old female client is admitted to the labor and delivery unit at 0700hrs. She is 34 weeks pregnant and reports having low back pain and frequent urination since last night. She mentions that urination is painful and she can only pass a small amount each time.
Question 1 of 5
Given the client's symptoms and the progression of her condition, the nurse suspects that the client may be experiencing complications related to preterm labor and a possible urinary tract infection (UTI). For each characteristic in the table, select whether it is more likely to be associated with preterm labor, a urinary tract infection (UTI), or both. Each column must have at least one response option selected. Candidates can select as many options as apply for each column.
| Complication | Preterm Labor | Urinary Tract Infection (UTI) |
|---|---|---|
| Frequent urination | ||
| Low back pain | ||
| Temperature of 38.3°C (101°F) | ||
| Strong urge to push | ||
| Contractions every 1.5 minutes | ||
| Pain level of 8 on a scale of 0 to 10 |
Correct Answer: A: UTI, B: Both, C: UTI, D: Preterm Labor, E: Preterm Labor, F: Both
Rationale: Frequent urination is more likely associated with a UTI due to irritation of the urinary tract. Low back pain can be associated with both preterm labor (due to uterine contractions) and UTI (due to kidney involvement). A temperature of 38.3°C (101°F) is more likely associated with a UTI, as fever is a common symptom of infection. A strong urge to push is indicative of preterm labor as it suggests advanced labor progression. Contractions every 1.5 minutes are a clear sign of preterm labor. A pain level of 8 can be associated with both conditions due to severe contractions in labor or significant infection-related discomfort in UTI.
Extract:
Medical History: Gravida: 2, Para: 1, Had an uncomplicated spontaneous vaginal birth 3 years ago of a 7 lb 4 oz infant, Client has no outstanding medical, social, or surgical history, Plan is to induce labor using oxytocin. Nurse's Notes at 0700 hrs: Client is resting in bed, appears anxious about the induction process. Reports mild, irregular contractions, stating they began around midnight. Fetal heart rate (FHR) is 140 beats per minute, with moderate variability. Cervix is 2 cm dilated, 50% effaced, and the fetal head is at -2 station. Client's partner is present and providing support. IV line is in place, and oxytocin infusion is started at 2 mU/min. Client is encouraged to ambulate as tolerated. Nurse's Notes at 0900 hrs: Client reports increased intensity and frequency of contractions, now occurring every 3-4 minutes. FHR is 145 beats per minute, with moderate variability and occasional accelerations. Cervix is now 4 cm dilated, 70% effaced, and the fetal head is at -1 station. Client is experiencing back pain and requests pain relief. IV oxytocin infusion is increased to 6 mU/min as per protocol. Client is repositioned to a side-lying position for comfort. Partner continues to provide support and encouragement. Vital Signs at 0700 hrs: Temperature: 37.2°C (99°F), Blood Pressure: 120/80 mmHg, Heart Rate: 82 beats per minute, Respiratory Rate: 18 breaths per minute. Vital Signs at 0900 hrs: Temperature: 37.5°C (99.5°F), Blood Pressure: 122/78 mmHg, Heart Rate: 88 beats per minute, Respiratory Rate: 20 breaths per minute. Diagnostic Results at 0900 hrs: Fetal scalp pH: 7.25, Amniotic fluid: Clear, no meconium present. A nurse is caring for a client who is 42 weeks of gestation.
Question 2 of 5
Based on the updated assessment findings, which of the following actions should the nurse plan to take? Click to specify whether the nurse's planned actions are anticipated, nonessential, or contraindicated.
| Action | anticipated | nonessential | contraindicated |
|---|---|---|---|
| Increase the oxytocin infusion to 13 mU/min | |||
| Place client in a side-lying position | |||
| Initiate bolus of primary IV fluids | |||
| Apply oxygen at 10 L/min via venturi mask | |||
| Perform sterile vaginal exam | |||
| Assign a Bishop score | |||
| Perform an amniotomy |
Correct Answer: A: Anticipated, B: Anticipated, C: Anticipated, D: Nonessential, E: Anticipated, F: Nonessential, G: Nonessential
Rationale: Increasing the oxytocin infusion to 13 mU/min is anticipated as contractions are progressing and cervical dilation is increasing. Placing the client in a side-lying position is anticipated to improve circulation and alleviate back pain. Initiating a bolus of IV fluids is anticipated to prevent dehydration during labor. Applying oxygen is nonessential as there are no signs of respiratory distress. Performing a sterile vaginal exam is anticipated to monitor labor progression. Assigning a Bishop score is nonessential since labor is already progressing. Performing an amniotomy is nonessential as labor is progressing normally without intervention.
Extract:
Nurses Notes at 0700: The client reports feeling generally well but mentions occasional episodes of dizziness and increased thirst. She has been monitoring her blood glucose levels at home and notes that they have been higher than usual. The client is concerned about the impact of her blood glucose levels on her pregnancy. She has been following a diet plan but admits to occasional deviations. The client denies any abdominal pain or contractions. Fetal movements are reported as normal. The client is advised to continue monitoring her blood glucose levels and to report any significant changes. Vital Signs at 0700: Temperature: 37.2°C (98.96°F), Blood Pressure: 130/85 mmHg, Heart Rate: 88 bpm, Respiratory Rate: 18 breaths/min. Diagnostic Results at 0700: Fasting blood glucose: 138 mg/dL (60 to 105 mg/dL), HbA1c: 6.4% (less than 6.5%), Urinalysis: Appearance: Clear, Color: Amber yellow, pH: 8.0 (4.6 to 8.0), Positive urine glucose (expected negative), 3+ ketones (expected negative), Urine specific gravity: 1.020 (1.005 to 1.030).
Question 3 of 5
Which of the following provider prescriptions should the nurse plan to implement? Select the 3 actions the nurse should plan to take.
Correct Answer: A, B, C
Rationale: Conducting a non-stress test twice per week monitors fetal well-being in high-risk pregnancies like gestational diabetes. Monitoring blood glucose daily is essential to manage gestational diabetes and prevent complications. Referring to a dietitian helps tailor a meal plan to control blood glucose. Refraining from physical activity is not recommended as exercise helps manage blood glucose levels.
Extract:
Vital Signs at 0700 hrs: Temperature: 36.6°C (97.9°F), Pulse: 85/min, Respiratory rate: 20/min, Blood pressure: 180/99 mm Hg. Nurses' Notes at 0700 hrs: Client reports, "I have had a headache for 2 days. Tylenol does not relieve it." Client states, "I have blurred vision and dizziness." Client reports swelling of their feet. 2+ pitting edema of the lower extremities noted bilaterally. Deep tendon reflexes 3+, absent clonus. Fetal heart tones (FH) 150/min. Medical History: Gravida 4 Para 3, 33 weeks of gestation, Allergies: Sulfa, Height: 165 cm (66 in), Weight: 82 kg (180 lb), BMI: 30.6.
Question 4 of 5
Select the 4 assessment findings the nurse should report to the provider.
Correct Answer: A, B, D, G
Rationale: Headache unrelieved by Tylenol, blurred vision and dizziness, 2+ pitting edema, and blood pressure of 180/99 mm Hg are concerning signs of preeclampsia, requiring immediate reporting. Swelling of feet is common and less urgent unless accompanied by other symptoms. Deep tendon reflexes 3+ and fetal heart tones 150/min are normal.
Extract:
A nurse in the newborn unit is caring for several infants.
Question 5 of 5
Which of the following situations requires the nurse's immediate attention and intervention?
Correct Answer: D
Rationale: Not passing meconium within 24 hours may indicate a bowel obstruction like meconium ileus, requiring immediate attention. Not voiding within 24 hours, acrocyanosis, and a temperature of 37.5°C are typically normal or less urgent findings.