ATI RN
VATI Maternal Newborn Assessment Questions
Question 1 of 9
A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?
Correct Answer: A
Rationale: The priority nursing intervention in this situation is to palpate the client's uterine fundus. Saturating two perineal pads with blood in a 30-minute period after childbirth is indicative of excessive postpartum bleeding, also known as postpartum hemorrhage (PPH). Palpating the uterine fundus helps the nurse assess for uterine atony, a common cause of PPH. If the fundus is boggy or not firm, it indicates that the uterus is not contracting effectively to control bleeding, which can lead to further complications if not addressed promptly. Once uterine atony is identified, other interventions such as administering oxytocic medications can be initiated to help the uterus contract and control bleeding.
Question 2 of 9
Narcotic analgesia is administered to a laboring patient at 10am. The infant is delivered at 12:30pm. The nurse would anticipate what?
Correct Answer: A
Rationale: Narcotic analgesia, when administered to a laboring patient, can cross the placenta and affect the infant. It can cause neonatal respiratory depression in the newborn after delivery. This is because the medication can depress the respiratory drive of the infant, leading to potentially serious breathing problems. It is important for the healthcare provider to closely monitor and assess the newborn for signs of respiratory distress in such cases.
Question 3 of 9
The nurse is monitoring a client in active labor. What finding indicates the need for immediate intervention?
Correct Answer: B
Rationale: A fetal heart rate of 90 beats/minute is bradycardia, indicating potential fetal distress.
Question 4 of 9
A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?
Correct Answer: A
Rationale: The priority nursing intervention in this situation is to palpate the client's uterine fundus. Saturating two perineal pads with blood in a 30-minute period after childbirth is indicative of excessive postpartum bleeding, also known as postpartum hemorrhage (PPH). Palpating the uterine fundus helps the nurse assess for uterine atony, a common cause of PPH. If the fundus is boggy or not firm, it indicates that the uterus is not contracting effectively to control bleeding, which can lead to further complications if not addressed promptly. Once uterine atony is identified, other interventions such as administering oxytocic medications can be initiated to help the uterus contract and control bleeding.
Question 5 of 9
During a trauma-informed gynecologic examination, what principle emphasizes the importance of involving the patient in decision making about their health care?
Correct Answer: A
Rationale:
Question 6 of 9
The nurse is monitoring a client with suspected placental abruption. What is a key assessment finding?
Correct Answer: B
Rationale: A hard, rigid abdomen and severe pain are classic signs of placental abruption, requiring urgent intervention.
Question 7 of 9
How would a patient who has taken Lamaze education respond when the health-care provider recommends breaking the bag of waters in early labor?
Correct Answer: C
Rationale: Lamaze encourages informed decision-making, prompting patients to ask about risks and benefits.
Question 8 of 9
What is the primary reason for administering Rh immunoglobulin to an Rh-negative mother after delivery?
Correct Answer: A
Rationale: Rh immunoglobulin prevents maternal sensitization to Rh-positive blood.
Question 9 of 9
What organization developed the CJMM?
Correct Answer: C
Rationale: The organization that developed the CJMM is the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). The CJMM, which stands for Core JMM, is a framework used for assessing labor progress during childbirth. AWHONN is a professional association that focuses on promoting the health of women and newborns, and they are widely recognized for their work in developing standards and guidelines in the field of obstetric and neonatal nursing.