ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Question 1 of 5
A nurse is collecting data from a client who is at 30 weeks of gestation. Which of the following findings should the nurse identify as a manifestation of pyelonephritis?
Correct Answer: B
Rationale: The correct answer is B: Flank pain. Pyelonephritis is an infection of the kidneys commonly characterized by flank pain. At 30 weeks of gestation, the uterus enlarges and can lead to obstruction of the ureters, increasing the risk of urinary stasis and infection. Epigastric discomfort (choice
A) is more indicative of issues like preeclampsia. Temperature elevation (choice
C) can be a sign of infection but is not specific to pyelonephritis. Abdominal cramping (choice
D) is more likely related to uterine contractions or gastrointestinal issues.
Question 2 of 5
A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: D
Rationale: The correct answer is D: "I will eliminate products that contain dairy from my diet." This is correct because dairy products can exacerbate nausea and vomiting in hyperemesis gravidarum. Dairy is often harder to digest and can trigger gastrointestinal distress. Avoiding dairy can help reduce symptoms and improve tolerance to food.
Choice A is incorrect because focusing on taste over balanced nutrition is not advisable for someone with hyperemesis gravidarum.
Choice B is irrelevant to the condition.
Choice C is also not recommended as caffeine in tea can worsen nausea.
Extract:
A nurse is assessing a postpartum client who delivered vaginally 8 hr ago.
Exhibit 1 - Nurses' Notes: 0700
Breasts soft, nipples intact. Uterus palpated firm, midline, and at the level of the umbilicus.
Moderate amount of lochia rubra. Episiotomy site well approximated with mild edema and
ecchymosis. Client reports pain as 2 on a scale of 0 to 10. Able to void spontaneously; no bladder
distention. Deep tendon reflexes 1+. Peripheral edema 2+ in bilateral lower extremities.
Exhibit 2 - Nurses' Notes: 1100
Breasts soft, nipples intact. Uterus palpated soft with lateral deviation and 1 cm above the
umbilicus. Large amount of lochia rubra. Episiotomy site well approximated with mild edema
and ecchymosis. Client reports pain as 3 on a scale of 0 to 10. Deep tendon reflexes 1+.
Peripheral edema 2+ in bilateral lower extremities.
Question 3 of 5
Select the 3 findings that require immediate follow-up.
Correct Answer: A,B,C
Rationale: The correct choices for immediate follow-up are A, B, and C. A lateral deviation of the uterus could indicate a potential complication like uterine prolapse. Deep tendon reflexes 1+ could suggest a neurological issue or electrolyte imbalance. A pain rating of 3 on a scale of 0 to 10 (increased) requires further assessment to determine the cause and provide appropriate treatment.
Choices D, E, F, and G are not as urgent. Peripheral edema 2+ bilateral lower extremities could be indicative of fluid retention, which may need monitoring but not immediate intervention. Soft uterine tone may be expected postpartum, and a large amount of lochia rubra could be normal after birth. A blood pressure of 136/86 mm Hg is slightly elevated but not critically high, so it may require monitoring but not immediate follow-up.
Extract:
Question 4 of 5
A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution. This is crucial because epidural anesthesia can cause hypotension, a common side effect. Monitoring the client's blood pressure closely allows for early detection of hypotension and prompt intervention to prevent potential complications like fetal distress. Placing the client in a supine position for 30 min (
A) is incorrect as it can lead to hypotension; administering dextrose solution (
B) is not necessary for epidural anesthesia; ensuring NPO status (
D) is important for other procedures but not specifically for epidural anesthesia.
Question 5 of 5
A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?
Correct Answer: D
Rationale:
Correct Answer: D - Verify that informed consent is obtained prior to administration.
Rationale: Informed consent is a crucial ethical and legal requirement before any medical procedure. It ensures the client is aware of the risks, benefits, and alternatives to the treatment. Verifying informed consent protects the client's autonomy and prevents potential legal issues.
Incorrect
Choices:
A: Allowing the medication to reach room temperature is not necessary for the administration of dinoprostone insert.
B: Placing the client in a semi-Fowler's position after administration is not a standard practice for this procedure.
C: Instructing the client to avoid urinary elimination is unnecessary and could lead to discomfort and potential complications.
E, F, G: No additional choices provided, but they would likely be incorrect as well as they do not address the key safety and ethical considerations associated with administering dinoprostone insert for labor induction.