ATI RN
test bank foundations of nursing Questions
Question 1 of 5
Spontaneous termination of a pregnancy is considered to be an abortion if
Correct Answer: A
Rationale: The correct answer is A because spontaneous termination of a pregnancy is considered an abortion if it occurs before 20 weeks gestation. This is based on the medical definition of abortion as the termination of a pregnancy before the fetus is able to survive outside the womb. Choices B, C, and D are incorrect as they do not accurately reflect the criteria for defining abortion. B and D are specific conditions related to the fetus and the presence of infection, while C refers to passing products of conception intact, which can happen in both spontaneous and induced abortions.
Question 2 of 5
Which assessment in a patient diagnosed with preeclampsia who is taking magnesium sulfate would indicate a therapeutic level of medication?
Correct Answer: C
Rationale: The correct answer is C: Normal deep tendon reflexes. This indicates a therapeutic level of magnesium sulfate as it shows that the medication is effectively preventing hyperreflexia, a common sign of magnesium toxicity. Drowsiness (choice A) can indicate toxicity. Urinary output of 20 mL/hour (choice B) is not specific to magnesium sulfate levels. Respiratory rate of 10 to 12 breaths per minute (choice D) is indicative of respiratory depression, a sign of magnesium toxicity. Thus, choice C is the best assessment to indicate a therapeutic level of medication in a patient with preeclampsia taking magnesium sulfate.
Question 3 of 5
As the triage nurse in the emergency room, you are reviewing results for the high-risk obstetric patient who is in labor because of traumatic injury experienced as a result of a motor vehicle accident (MVA). You note that the Kleihauer–Betke test is positive. Based on this information, you anticipate that
Correct Answer: A
Rationale: The correct answer is A: immediate birth is required. The Kleihauer–Betke test is used to detect fetal-maternal hemorrhage in situations where there is a risk of fetal blood entering the maternal circulation, such as trauma during pregnancy. A positive result indicates a significant fetal-maternal hemorrhage, which can lead to Rh incompatibility and severe fetal anemia. Immediate birth is required to prevent complications and ensure the safety of both the mother and the baby. Choice B is incorrect as transferring the patient to the critical care unit does not address the underlying issue of fetal-maternal hemorrhage. Choice C is incorrect as RhoGAM is typically administered to prevent Rh sensitization in Rh-negative mothers carrying Rh-positive babies, which is not the primary concern in this scenario. Choice D is incorrect as a tetanus shot is not directly related to the positive Kleihauer–Betke test result indicating fetal-maternal hemorrhage.
Question 4 of 5
Which intervention is the priority for the patient diagnosed with an intact tubal pregnancy?
Correct Answer: B
Rationale: The correct answer is B: Administration of methotrexate. This is the priority intervention for an intact tubal pregnancy to prevent further growth and potential rupture of the fallopian tube. Methotrexate is a medication used to stop the growth of the pregnancy tissue. Assessment of pain level (A) is important but not the priority as immediate intervention to address the ectopic pregnancy is crucial. Administration of Rh immune globulin (C) is not the priority in this situation, as it is typically given after a miscarriage or abortion to prevent Rh sensitization. Explanation of common side effects (D) is important for patient education, but it is not the immediate priority when dealing with an ectopic pregnancy.
Question 5 of 5
A labor and birth nurse receives a call from the laboratory regarding a preeclamptic patient receiving an IV infusion of magnesium sulfate. The laboratory technician reports that the patient’s magnesium level is 6 mg/dL. What is the nurse’s priority action?
Correct Answer: A
Rationale: The correct answer is A: Stop the infusion of magnesium. A magnesium level of 6 mg/dL is above the therapeutic range (4-7 mg/dL) for preeclamptic patients receiving magnesium sulfate. Continuing the infusion can lead to magnesium toxicity, causing respiratory depression, cardiac arrest, and neuromuscular blockade. Stopping the infusion is crucial to prevent further complications. Assessing the patient's respiratory rate (B) and deep tendon reflexes (C) are important, but stopping the infusion takes priority to prevent harm. Notifying the health care provider (D) is important but may delay immediate action to address the high magnesium level.