ATI RN
RN ATI Maternal Newborn 2023 with NGN Questions
Question 1 of 5
A nurse is caring for a client who is in labor and reports increasing rectal pressure. They are experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that their cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?
Correct Answer: D
Rationale: The correct answer is D: Descent. At 9 cm dilation, the client is in the second stage of labor, which consists of the descent and birth of the baby. Increasing rectal pressure indicates the baby is descending into the birth canal. Contractions 2-3 min apart lasting 80-90 seconds are characteristic of the active phase of the second stage. Passive descent (choice
A) refers to the initial descent of the baby before the active pushing stage. Active (choice
B) and early (choice
C) phases are terms used for the first stage of labor, not the second stage. The client's dilation and symptoms clearly indicate they are in the descent phase of the second stage of labor.
Question 2 of 5
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on bed rest. This is important to prevent dislodgement of the clot and further complications associated with thrombophlebitis. Moving the client around can increase the risk of clot migration. Administering aspirin for pain (choice
A) is not appropriate as it can increase the risk of bleeding with heparin therapy. Massaging the affected leg every 12 hours (choice
C) can also dislodge the clot and is contraindicated. Applying cold compresses to the affected calf (choice
D) can also increase the risk of clot dislodgement.
Therefore, the best action is to maintain the client on bed rest to minimize the risk of complications.
Extract:
Exhibit1 Graphic Record: Blood pressure 130/78 mm Hg Respiratory rate 20/min Heart rate 90/min
Exhibit2:Diagnostic Results Hemoglobin 12 g/dL (11 to 16 g/dL) Hematocrit 34% (33% (0 47%) 1-hr glucose tolerance test 120 mg/dL (less than 180-190 mg/dL)
Exhibit3 Progress Notes FundalFundal height 30 cm Good fetal movement Not experiencing headache, dizziness, blurred vision, or vaginal bleedingFetal heart rate 110/min
Question 3 of 5
A nurse in an antepartum clinic is providing weeks of gestation. Upon reviewing the following findings should the nurse report to the provider? (Click on the 'Exhibit' button for additional information about the client. There are three tabs that contain separate categories of data.)
Correct Answer: D
Rationale: The correct answer is D: Fetal heart rate (FHR). The nurse should report any abnormal fetal heart rate findings to the provider as it could indicate fetal distress or other complications. Monitoring FHR is crucial for assessing fetal well-being.
A: 1-hr glucose tolerance test is not relevant to the assessment of fetal well-being in this scenario.
B: Hematocrit is important for assessing the mother's blood volume but does not directly relate to fetal well-being.
C: Fundal height measurement helps estimate fetal growth but would not necessarily indicate an immediate concern that needs to be reported to the provider.
In summary, monitoring the FHR is essential for assessing fetal well-being and any abnormalities should be promptly reported for further evaluation and management.
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 to assess for any potential hypotension, a common side effect of epidural anesthesia. Close monitoring allows for prompt intervention if hypotension occurs, ensuring the client's safety.
Choice A is incorrect because placing the client in a supine position following epidural anesthesia can lead to hypotension.
Choice B is incorrect as administering dextrose solution is not necessary for epidural anesthesia.
Choice D is incorrect as NPO status is not required for epidural anesthesia administration.
Question 5 of 5
A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority?
Correct Answer: B
Rationale: The correct answer is B. Epigastric pain in a pregnant woman at 34 weeks could indicate a serious condition like pre-eclampsia, which requires immediate attention to prevent complications for both the mother and the baby. Gestational diabetes with a fasting blood glucose level of 120 mg/dL, as in choice A, is concerning but can be managed with appropriate interventions and monitoring.
Choice C's client with an Hgb of 10.4 g/dL is below the normal range but not an immediate priority unless there are symptoms of severe anemia.
Choice D's client at 39 weeks with urinary symptoms may indicate a urinary tract infection, which is important but not as urgent as potential pre-eclampsia.