ATI RN
Chimat Maternity Needs Assessment Questions
Question 1 of 5
The parents of a male newborns have signed an informed consent for circumcision. which intervention should the nurse implement upon completion of the circumcision?
Correct Answer: A
Rationale: In this scenario, the correct intervention is option A) Place petroleum gauze dressings on the site. This intervention is crucial for wound care post-circumcision as it helps protect the incision site from contamination and promotes healing. Option B) Wrap the infant in warm receiving blankets is not the most appropriate intervention after circumcision as it does not address the specific wound care needs of the circumcision site. Option C) Giving a PRN dose of liquid acetaminophen may be appropriate for pain management after circumcision, but it is not the immediate intervention needed post-procedure. Option D) Offering a pacifier dipped in glucose water is not recommended as the primary intervention after circumcision. This intervention does not address the wound care needs of the circumcision site and may not be appropriate for newborns. Educationally, it is important for nurses to understand the post-circumcision care protocol to ensure proper wound healing and prevent complications. Nurses should be knowledgeable about wound care, pain management, and comfort measures for newborns undergoing circumcision to provide safe and effective care.
Question 2 of 5
A woman in her third trimester of pregnancy has been in active labor for the past 8 hours and cervix dialed 3 cm. The nurse's assessment findings and electronic fetal monitoring (EFM) are consistent with hypotonic dystocia, and the healthcare provider prescribes an oxytocin drip. Which data is most important for the nurse to monitor?
Correct Answer: C
Rationale: In this scenario, the correct answer is option C: Intensity, interval, and length of contractions. Monitoring these factors is crucial when managing hypotonic dystocia with an oxytocin drip. The nurse must assess the effectiveness of the medication in increasing the frequency, strength, and duration of contractions to progress labor. Option A (Clients hourly blood pressure) is incorrect as it is not the priority in this situation. While monitoring blood pressure is essential in pregnancy, in the context of managing hypotonic dystocia, assessing contractions is more pertinent. Option B (Preparation for emergency cesarean birth) is premature at this point as the first step in managing hypotonic dystocia is to attempt to augment labor with oxytocin. Cesarean birth should be considered if labor fails to progress despite oxytocin augmentation and other interventions. Option D (Checking the perineum for bulging) is not as critical as monitoring contractions in this case. Perineal assessment is important in the second stage of labor to determine fetal descent, but in the context of hypotonic dystocia, monitoring contractions takes precedence. Educationally, understanding the rationale behind monitoring contraction patterns in hypotonic dystocia helps students grasp the importance of timely and appropriate interventions in obstetric emergencies, promoting safe and effective maternal and fetal outcomes.
Question 3 of 5
A client who delivered a healthy newborn an hour ago asks the nurse when she can go home. Which information is most important for the nurse to provide the client?
Correct Answer: C
Rationale: The correct answer is option C: "When there is no significant vaginal bleeding." This is the most important information for the nurse to provide the client because it indicates the status of the client's postpartum bleeding, which is a crucial aspect to monitor following delivery. Significant vaginal bleeding could be a sign of postpartum hemorrhage, a serious complication that requires immediate medical attention to prevent further complications or harm to the mother. Option A, "When ambulating to void does not cause dizziness," while important for the client's safety, is not as critical as monitoring for postpartum bleeding. Option B, "After the vitamin K injection is given to the baby," and Option D, "After the baby no longer demonstrates acrocyanosis," are related to the newborn's care and not directly relevant to the client's discharge readiness. In an educational context, this question emphasizes the importance of prioritizing postpartum assessment and teaching in maternity care. Nurses need to educate clients on postpartum warning signs, including excessive bleeding, to ensure optimal postpartum recovery and prevent complications. This scenario highlights the nurse's role in providing essential information to empower clients to make informed decisions about their health and well-being during the postpartum period.
Question 4 of 5
At 0600 while admitting a woman for a scheduled repeat Caesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?
Correct Answer: C
Rationale: In this scenario, the correct action for the nurse to take first is to inform the anesthesia care provider (Option C). The client drinking coffee close to the scheduled C-section time is crucial information because caffeine can affect anesthesia. Anesthesia providers need to be aware of any substance consumption that can impact the anesthesia plan to ensure the client's safety during the procedure. Option A (Contact the client's obstetrician) is incorrect because the immediate concern is the impact of caffeine on anesthesia, which falls under the anesthesia provider's purview. Option B (Ensure preoperative lab results are available) is not the priority as the client's recent caffeine intake poses a more urgent issue. Option D (Start prescribed IV with Lactated Ringer's) is not the best initial action as addressing the caffeine intake's potential impact on anesthesia takes precedence. Educationally, this scenario highlights the importance of thorough preoperative assessments and the need to communicate pertinent information promptly to the appropriate members of the healthcare team. It also emphasizes the critical role nurses play in advocating for patient safety by ensuring all relevant details are shared with the anesthesia team for optimal patient outcomes.
Question 5 of 5
A client at 20 weeks gestation comes to antepartum clinic complaining of vaginal warts (human papilloma virus HPV). What information should the nurse provide this client?
Correct Answer: B
Rationale: In this scenario, option B is the correct answer. The nurse should inform the client that pregnancy complications are not directly linked to HPV. It is important for the nurse to provide accurate and evidence-based information to the client. HPV, the virus that causes genital warts, does not typically lead to pregnancy complications. It is essential for the nurse to reassure the client and alleviate any concerns regarding the impact of HPV on her pregnancy. Option A is incorrect because termination of the pregnancy is not indicated solely based on the presence of HPV. Option C is incorrect because acyclovir (Zovirax) is used to treat herpes simplex virus (HSV) infections, not HPV. Option D is incorrect because penicillin G is an antibiotic used to treat bacterial infections, not viral infections like HPV. Educationally, this question highlights the importance of providing accurate and non-alarming information to pregnant clients. Nurses play a crucial role in educating clients about their health conditions and dispelling any myths or misconceptions. It is essential for healthcare providers to offer evidence-based information to empower clients to make informed decisions about their health and pregnancy.