ATI RN
ATI Nurs 140 exam Maternal Newborn Questions
Extract:
A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is 'not really sure if she is in labor or not.'
Question 1 of 5
A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is 'not really sure if she is in labor or not.' Which of the following should the nurse recognize as a sign of true labor?
Correct Answer: A
Rationale: As labor begins, the cervix starts to soften, shorten, and thin (efface). This process is often expressed in percentages. This is a definitive sign of true labor as it indicates cervical progression necessary for delivery.
Extract:
Client was middle aged and married. She was in labor for 25 hours and forceps were used to assist with the delivery. She was given an epidural for anesthesia that was effective. The labor and delivery nurse reported that the client had a 4th degree laceration, and her pain was currently at a 4 on a 0 to 10 pain scale. Her vital signs were stable, and she was catheterized for 500 mL of light-yellow urine just prior to delivery. Her spouse was at the bedside for delivery.
Question 2 of 5
The nurse is reviewing the client's chart. Click to highlight areas of client history and physical that increase the risk for postpartum hemorrhage.
Correct Answer: B, C, D
Rationale: Forceps-assisted delivery, a 4th degree laceration, and prolonged labor (25 hours) increase the risk of postpartum hemorrhage due to potential trauma to the birth canal and uterine atony.
Extract:
The patient has an area over the sacrum that is reddened around the edges with a blackened area in the center.
Question 3 of 5
The patient has an area over the sacrum that is reddened around the edges with a blackened area in the center. How would you document this wound?
Correct Answer: A
Rationale: An unstageable pressure ulcer is documented due to the presence of eschar (blackened area) in the wound bed, indicating full-thickness tissue loss that cannot be staged until the eschar is removed.
Extract:
A nurse is caring for a client who is at 34 weeks of gestation. The client has a medical history of gestational diabetes, preeclampsia with previous pregnancy, and chronic hypertension for 5 years. The client's vital signs are: BP: 170/104 mm Hg, Pulse: 89/min, Respirations: 20/min, Temperature: 98.8°F (37.1°C) Oral, Oxygen saturation: 97% room air. The client's physical examination shows: Respirations even and unlabored, Awake, alert, and oriented to person, place, and time, Pedal pulse strong and regular bilaterally, 3+ edema in lower extremities.
Question 4 of 5
A nurse is caring for a client who is at 34 weeks of gestation. The client has a medical history of gestational diabetes, preeclampsia with previous pregnancy, and chronic hypertension for 5 years. The client's vital signs are: BP: 170/104 mm Hg, Pulse: 89/min, Respirations: 20/min, Temperature: 98.8°F (37.1°C) Oral, Oxygen saturation: 97% room air. The client's physical examination shows: Respirations even and unlabored, Awake, alert, and oriented to person, place, and time, Pedal pulse strong and regular bilaterally, 3+ edema in lower extremities. What are the two most important nursing diagnoses for this client?
Correct Answer: A, B
Rationale: Risk for injury due to seizures is critical in severe preeclampsia, as seizures can cause maternal and fetal harm. Impaired gas exchange due to potential pulmonary edema is significant given the client's fluid overload risk from high BP and edema.
Extract:
A nurse midwife is examining a client who is primigravida at 42 weeks of gestation and states that she believes she is in labor.
Question 5 of 5
A nurse midwife is examining a client who is 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?
Correct Answer: B
Rationale: Cervical dilation is a definitive sign of labor, indicating the cervix is opening and thinning to allow fetal passage, measured in centimeters from 0 to 10.