ATI RN
ATI Maternal Newborn Proctored Exam Latest Update Questions
Extract:
Question 1 of 5
A 35-week gestation infant was delivered by forceps. Which assessment findings should alert the nurse to a possible complication of the forceps delivery?
Correct Answer: A
Rationale: The correct answer is A: Weak, ineffective suck, and scalp edema. Forceps delivery can cause head trauma leading to facial nerve injury, resulting in weak suck and scalp edema. Molding of the head (choice
B) is a normal finding after vaginal birth. Jitteriness (choice
B) may be due to immaturity rather than a complication of forceps delivery. A shrill, high-pitched cry and tachypnea (choice
C) are more indicative of respiratory distress, not specific to forceps delivery. Hypothermia and hemoglobin of 12.5 g/dL (choice
D) are not directly related to complications of forceps delivery.
Question 2 of 5
In which position should the nurse place the laboring client in order to increase the intensity of the contractions and improve oxygenation to the fetus?
Correct Answer: C
Rationale: The correct answer is C, left side-lying position. This position promotes optimal blood flow to the placenta, enhancing oxygenation to the fetus. It also helps prevent compression of the vena cava, ensuring adequate circulation to the mother. Supine position with legs elevated (
A) can compress the vena cava, reducing blood flow to the fetus. Squatting (
B) may not improve oxygenation to the fetus and can be tiring for the laboring client. High Fowler's position (
D) can impede blood flow to the placenta due to compression of abdominal vessels.
Question 3 of 5
A woman enters the birthing center in active labor. She tells the nurse that her membranes ruptured 26 hours ago. The nurse immediately takes the client's vital signs. Which is the rationale for the nurse's actions?
Correct Answer: D
Rationale: The correct answer is D. When the membranes rupture, it increases the risk of infection as it provides a direct pathway for bacteria to enter the uterus. Taking vital signs is crucial to monitor for signs of infection such as fever, tachycardia, and hypotension. Elevated temperature and increased heart rate can indicate an infection.
Choice A is incorrect because pulse rate may not necessarily rise with prolonged rupture of membranes.
Choice B is also incorrect as respiratory rates are not directly affected by ruptured membranes.
Choice C is incorrect as prolonged rupture can lead to infection rather than transient hypertension.
Question 4 of 5
A new client's pregnancy is confirmed at 10 weeks gestation. Her history reveals that her first two pregnancies ended in spontaneous abortion at 12 and 20 weeks. She has a 4-year-old and a set of 1-year-old twins. How should the nurse record the client's current gravida and para status?
Correct Answer: C
Rationale: The correct answer is C: Gravida 5, para 2. Gravida refers to the total number of pregnancies, including the current one. The client is currently pregnant (1), had two spontaneous abortions (2), a 4-year-old (3), and a set of 1-year-old twins (4-5). Para refers to the number of viable births (past the age of viability). The client has a 4-year-old and a set of 1-year-old twins, totaling 2 live births.
Therefore, the correct status is Gravida 5, para 2.
Choice A (Gravida 2, para 3) is incorrect because it does not account for the client's current pregnancy and the twins.
Choice B (Gravida 4, para 2) is incorrect as it overlooks the client's previous spontaneous abortions.
Choice D (Gravida 5, para 4) is incorrect as it includes all
Question 5 of 5
A 16-year-old client reports to the school nurse because of nausea and vomiting. After exploring the signs and symptoms with the client, the nurse asks the girl whether she could be pregnant. The girl confirms that she is pregnant, but states that she does not know how it happened. Which nursing diagnosis is most important?
Correct Answer: D
Rationale: The correct answer is D: Knowledge deficit related to the client's developmental stage and age. This nursing diagnosis is most important because the client's lack of understanding about how pregnancy occurs indicates a significant gap in knowledge. It is crucial to provide education on sexual health and reproduction to prevent future unplanned pregnancies and promote informed decision-making.
Choice A is incorrect as addressing altered nutrition is important but not the priority in this situation.
Choice B is incorrect as the client's age does not necessarily indicate a need for immediate intervention in family processes.
Choice C is incorrect as the primary issue is the client's lack of knowledge, not denial of pregnancy.
In summary, choice D is the most important nursing diagnosis as it directly addresses the root cause of the client's situation and has the potential to positively impact her future health and well-being.