ATI RN
ATI Maternity Nur230 Questions
Extract:
Client in labor at 2 cm dilation, 50% effaced, fetus at -2 station
Question 1 of 5
A nurse in the labor and delivery unit is attending to a client in labor. The nurse applies an external fetal monitor and toco transducer. The FHR is around 140/min. Contractions are every 8 min and 30 to 40 seconds in duration. The nurse performs a vaginal exam and finds the cervix is 2 cm dilated, 50% effaced, and the fetus is at a -2 station. Which stage and phase of labor is this client experiencing?
Correct Answer: D
Rationale: The latent phase of the first stage involves mild, irregular contractions, 0-3 cm dilation, and 0-40% effacement, matching these findings.
Extract:
Multiple clients on the postpartum unit
Question 2 of 5
A nurse is providing care to multiple clients on the postpartum unit. Which of the following clients is at the greatest risk for developing a puerperal infection?
Correct Answer: C
Rationale: An erythematous episiotomy extended to a third-degree laceration increases infection risk due to the deeper tissue involvement and potential for bacterial growth.
Extract:
Newborn with an apical heart rate of 130/min
Question 3 of 5
A nurse is caring for a newborn and hears an apical heart rate of 130/min. What should the nurse do next?
Correct Answer: A
Rationale: A heart rate of 130/min is within the normal range (120-160 bpm) for a newborn, requiring only documentation.
Extract:
7-year-old child with unexplained bruising, red spots, prolonged cold, nosebleed, and limb pain
Question 4 of 5
A nurse is caring for a 7-year-old child who was brought in by parents due to unexplained bruising and red spots on the child's shoulders, thighs, and back. The parents report that the child has had a cold for more than 2 months and over-the-counter medications have not helped relieve the cold symptoms. The child had a small nosebleed 'a few minutes ago' and reports 'my arms and legs hurt all over.' For each assessment finding, specify if the finding is consistent with sickle cell anemia or hemophilia.
| Finding | Sickle cell anemia | Hemophilia |
|---|---|---|
| WBC count | ||
| Temperature | ||
| Bleeding | ||
| Reported pain |
Correct Answer: A(none), B(none), C(hemophilia), D(sickle cell anemia)
Rationale: Bleeding aligns with hemophilia due to clotting issues; pain is typical in sickle cell anemia from vascular occlusion.
Extract:
Child with heart diseases
Question 5 of 5
Which of the following heart diseases are considered acquired? Select all that apply.
Correct Answer: A,B,D
Rationale: Infective endocarditis, Kawasaki disease, and cardiomyopathy are acquired, developing during a person's lifetime, unlike congenital defects present at birth.