ATI RN
ATI RN Maternal Newborn Updated 2023 Questions
Extract:
A client in the postpartum unit.
Question 1 of 5
Which of the following goals should the nurse identify for the client to accomplish during the taking-in phase of postpartum adjustment?
Correct Answer: D
Rationale: During the taking-in phase of postpartum adjustment, the focus is on the mother's own physical recovery and well-being.
Therefore, the most appropriate goal for the nurse to identify during this phase is D: The client will have adequate nutritional intake. This is crucial for the mother's own health and healing after childbirth. Proper nutrition supports her energy levels, helps with tissue repair, and aids in milk production if she chooses to breastfeed. The other choices are not as relevant during this phase. A and B are more related to infant care and safety, which are typically addressed in the later phases of postpartum adjustment. C involves family dynamics, which may be more pertinent in the later postpartum phases when the mother is more emotionally ready to focus on family roles.
Extract:
A client who is postpartum and just delivered a newborn who weighs 4.5 kg (10 lb).
Question 2 of 5
Which of the following manifestations should the nurse recognize as a potential sign of hemorrhage?
Correct Answer: A
Rationale: The correct answer is A. A blood pressure of 88/40 mm Hg is indicative of hypotension, which is a common sign of hemorrhage due to decreased blood volume. Hypotension results from the body's compensatory mechanisms to maintain perfusion. Options B, C, and D are not specific indicators of hemorrhage. Urinary output of 40 mL/hr is within normal range, moderate rubra lochia is expected in the postpartum period, and a heart rate of 90/min is not necessarily abnormal. It is crucial for the nurse to recognize hypotension as a potential sign of hemorrhage to intervene promptly and prevent further complications.
Extract:
A client who is in the second stage of labor and is experiencing a shoulder dystocia.
Question 3 of 5
Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Assist the client in pulling their knees toward their abdomen. This position helps facilitate the delivery of the baby by widening the pelvic outlet, reducing pressure on the perineum, and promoting descent of the fetus. This action also eases the process of childbirth and minimizes the risk of perineal tears.
Choice B is incorrect as pressing firmly on the client's suprapubic area can increase discomfort and is not a recommended practice during labor.
Choice C, moving the client onto their hands and knees, may not be suitable for all women and does not provide the same benefits as pulling knees toward the abdomen.
Choice D, applying pressure to the client's fundus, is not recommended during labor as it can cause complications.
Extract:
A client who is 6 hr postpartum and is saturating perineal pads every 10 to 15 min.
Question 4 of 5
Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Collect hemoglobin and hematocrit levels. This is the first action the nurse should take to assess the client's oxygen-carrying capacity and hydration status. It provides crucial data for determining the client's overall health status. Inserting an indwelling urinary catheter (
B) is not the priority unless indicated. Administering oxygen via face mask (
C) is important, but assessing the client's hemoglobin and hematocrit levels takes precedence. Preparing the client to receive a plasma expander (
D) should only be done after assessing the client's current status.
Extract:
A client who is taking an oral contraceptive.
Question 5 of 5
The nurse should instruct the client to report which of the following findings to the provider immediately?
Correct Answer: B
Rationale: The correct answer is B: Persistent headaches. Headaches can indicate serious conditions like hypertension or preeclampsia, requiring immediate medical attention to prevent complications. Breast tenderness, vaginal itching, and painful intercourse are common discomforts during pregnancy but typically not urgent issues. Reporting persistent headaches promptly can ensure timely intervention and prevent potential risks to the client and fetus.