ATI RN
ATI RN Maternal Newborn Latest Update. Questions
Question 1 of 5
A nurse is caring for a client who is receiving oxytocin via continuous IV infusion and is experiencing persistent late decelerations in the FHR. After discontinuing the infusion, which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen at 10 L/min via nonrebreather facemask. This action is appropriate because late decelerations in fetal heart rate (FHR) can indicate uteroplacental insufficiency, leading to fetal hypoxia. Administering oxygen helps increase the oxygen supply to the fetus, potentially improving fetal oxygenation and reducing the risk of hypoxia-related complications.
Choice A is incorrect because bearing down and pushing with contractions can further compromise fetal oxygenation in the presence of late decelerations.
Choice C is incorrect as a supine position can worsen uteroplacental perfusion.
Choice D, initiating an amnioinfusion, is not indicated for addressing late decelerations in FHR.
Question 2 of 5
A nurse is reviewing the prescriptions for a client who is pregnant and is taking digoxin. Which of the following actions should the nurse take to best evaluate the client’s medication adherence?
Correct Answer: D
Rationale: The correct answer is D: Check the client's serum medication level. This is the best way to evaluate medication adherence for digoxin. Digoxin has a narrow therapeutic range, so monitoring the serum level ensures the client is taking the correct dose.
Choices A, B, and C do not directly assess medication adherence for digoxin. Asking the client may not reflect the actual medication intake, kidney function assessment is important but not for adherence evaluation, and apical pulse rate may be affected by various factors. Checking the serum level provides objective data on the drug concentration in the body, indicating adherence.
Extract:
A nurse is caring for a client who is experiencing a postpartum hemorrhage and has a new prescription for misoprostol.
Exhibit 2: Medical History
Preeclampsia
Cesarean birth of viable twin male newborns
Question 3 of 5
The nurse is assessing the client 30 min later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
| Findings 30 min later | Unrelated to diagnosis | Indication Of potential improvement | Indication of Potential worsening condition |
|---|---|---|---|
| Fundus at level of umbilicus | |||
| Cloudy urine | |||
| Blood pressure 80/50 mm Hg | |||
| Moderate lochia rubra | |||
| Thready pulse | |||
| Fundus firm to palpation |
Correct Answer:
Rationale: The correct answer is . Fundus at the level of the umbilicus is an indication of potential improvement as it shows proper involution of the uterus. Cloudy urine is unrelated to the diagnosis and may indicate a urinary tract infection. Blood pressure of 80/50 mm Hg is an indication of potential worsening condition as it is considered hypotension. Moderate lochia rubra is an expected finding postpartum. Thready pulse is not included in the provided parameters, so it is not considered in the analysis.
Extract:
Question 4 of 5
A nurse is caring for a client who is receiving an epidural block with an opioid analgesic. The nurse should monitor for which of the following findings as an adverse effect of the medication?
Correct Answer: C
Rationale:
Correct
Answer: C - Hypotension
Rationale: Opioid analgesics can cause vasodilation leading to hypotension due to decreased systemic vascular resistance. The nurse should monitor the client for signs of hypotension such as lightheadedness, dizziness, and decreased blood pressure. Monitoring for hypotension is crucial to prevent complications like decreased perfusion to vital organs.
Summary:
A: Hyperglycemia - Opioid analgesics do not typically cause hyperglycemia.
B: Bilateral crackles - This finding is more indicative of fluid overload or heart failure, not a direct effect of opioid analgesics.
D: Polyuria - Opioid analgesics do not usually cause polyuria; in fact, they can cause urinary retention as a side effect due to bladder sphincter relaxation.
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 5 of 5
Select the 3 findings that require immediate follow-up.
Correct Answer: A,B,C
Rationale: The correct answers are A, B, and C. A lateral deviation of the uterus could indicate a potential complication such as uterine inversion. Deep tendon reflexes being 1+ may suggest hyporeflexia, which could be a sign of neurological issues. A pain rating of 3 on a scale of 0 to 10, especially if increased, may indicate worsening pain that needs immediate attention.
Choices D, E, F, and G do not require immediate follow-up as they are not indicative of urgent conditions. Peripheral edema 2+ bilateral lower extremities may be normal postpartum. Uterine tone being soft is expected in the postpartum period. A large amount of lochia rubra is typically seen in the immediate postpartum period. Blood pressure of 136/86 mm Hg is within normal limits for a postpartum patient.