ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 of 5
A nurse is assessing a client who is postpartum following a cesarean birth. The client states, 'I feel like I have to urinate but I can’t go.' Which of the following actions should the nurse take?
Correct Answer: A
Rationale:
Rationale:
Choice A is correct because assisting the client to ambulate to the bathroom can help relieve pressure on the bladder and facilitate urination. Walking can also help stimulate bladder emptying. Inserting a urinary catheter (
Choice
B) is invasive and should be avoided unless necessary. Performing a bladder scan (
Choice
C) may be considered if the client continues to have difficulty urinating after ambulating. Administering a diuretic (
Choice
D) is not indicated as it may exacerbate the issue by increasing urine production without addressing the underlying cause.
Question 2 of 5
A nurse is caring for a client who is 1 hr postpartum and has uterine atony. The client is exhibiting a large amount of vaginal bleeding. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Anticipate a prescription for misoprostol. Misoprostol is a medication used to help control postpartum hemorrhage by promoting uterine contractions which can help stop the bleeding due to uterine atony. It is important to address the underlying cause of the bleeding to prevent further complications.
Choice A: Administering betamethasone IM is not appropriate in this situation as it is a corticosteroid used to promote fetal lung development in preterm labor, not for controlling postpartum hemorrhage.
Choice B: Avoiding performing sterile vaginal examinations is not helpful in managing postpartum hemorrhage. Vaginal examinations may be necessary to assess the degree of bleeding and uterine tone.
Choice D: Obtaining a specimen for a Kleihauer-Betke test is used to determine the amount of fetal-maternal hemorrhage in cases of Rh incompatibility, not for immediate management of postpart
Extract:
A nurse is caring for a client who is pregnant in an antepartum clinic.
Vital Signs
0900:
Temperature 36.6°C (97.9°F)
Heart rate 88/min
Respiratory rate 18/min
Blood pressure 130/70 mm Hg
Oxygen saturation 97% on room air
1000:
Heart rate 76/min
Respiratory rate 20/min
Blood pressure 138/68 mm Hg
Oxygen saturation 98% on room air
Question 3 of 5
Which of the following findings should the nurse report to the provider?Select the 3 findings that should be reported.
Correct Answer: A,B,D
Rationale: The nurse should report uterine contractions (
A) as they can indicate preterm labor. Fetal heart rate (
B) should be reported to monitor fetal well-being. Vaginal examination (
D) findings are important to assess cervical changes. Gestational age (
C) and maternal blood pressure (E) are routine assessments and do not necessarily require immediate reporting.
Extract:
A nurse is assessing a postpartum client who delivered vaginally 8 hr ago.
Exhibit 1 - Nurses' Notes: 0700
Breasts soft, nipples intact. Uterus palpated firm, midline, and at the level of the umbilicus.
Moderate amount of lochia rubra. Episiotomy site well approximated with mild edema and
ecchymosis. Client reports pain as 2 on a scale of 0 to 10. Able to void spontaneously; no bladder
distention. Deep tendon reflexes 1+. Peripheral edema 2+ in bilateral lower extremities.
Exhibit 2 - Nurses' Notes: 1100
Breasts soft, nipples intact. Uterus palpated soft with lateral deviation and 1 cm above the
umbilicus. Large amount of lochia rubra. Episiotomy site well approximated with mild edema
and ecchymosis. Client reports pain as 3 on a scale of 0 to 10. Deep tendon reflexes 1+.
Peripheral edema 2+ in bilateral lower extremities.
Question 4 of 5
Select the 3 findings that require immediate follow-up.
Correct Answer: A,B,C
Rationale: The correct choices for immediate follow-up are A, B, and C. A lateral deviation of the uterus could indicate a potential complication like uterine prolapse. Deep tendon reflexes 1+ could suggest a neurological issue or electrolyte imbalance. A pain rating of 3 on a scale of 0 to 10 (increased) requires further assessment to determine the cause and provide appropriate treatment.
Choices D, E, F, and G are not as urgent. Peripheral edema 2+ bilateral lower extremities could be indicative of fluid retention, which may need monitoring but not immediate intervention. Soft uterine tone may be expected postpartum, and a large amount of lochia rubra could be normal after birth. A blood pressure of 136/86 mm Hg is slightly elevated but not critically high, so it may require monitoring but not immediate follow-up.
Extract:
Question 5 of 5
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
Correct Answer: C
Rationale: The correct answer is C: Assist the client to empty their bladder. A uterus palpated to the right above the umbilicus in a postpartum client indicates a full bladder displacing the uterus. This can lead to uterine atony and increase the risk of postpartum hemorrhage. By assisting the client to empty their bladder, the nurse can help the uterus contract properly and prevent complications.
Other choices are incorrect:
A: Reassessing in 2 hours does not address the immediate issue of a full bladder causing uterine displacement.
B: Administering simethicone is used for gas relief and is not relevant in this situation.
D: Instructing the client to lie on their right side does not address the underlying issue of a full bladder.
In summary, emptying the bladder is crucial to prevent complications post-vaginal delivery, making it the most appropriate intervention in this scenario.