ATI RN
RN Maternal Nursing OB Newborn 2023 2024 Exam 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: The correct answer is A: Assist the client to ambulate to the bathroom. This action helps in promoting normal voiding patterns post-cesarean birth. Ambulation can aid in relieving pressure on the bladder, stimulating the urge to urinate, and facilitating the flow of urine. It also promotes circulation, which can help in reducing the risk of urinary retention.
Choice B: Inserting an indwelling urinary catheter should not be the initial intervention as it carries a risk of introducing infection and may not be necessary at this point.
Choice C: Performing a bladder scan can be considered if the client is unable to void after ambulation and other interventions have been attempted.
Choice D: Administering a diuretic is not appropriate in this situation as the client is experiencing difficulty in urinating rather than retaining excessive urine.
In summary, assisting the client to ambulate to the bathroom is the most appropriate initial action to address the client's complaint and promote normal voiding.
Question 2 of 5
A nurse is caring for a newborn who is 12 hr old and is experiencing jitteriness. Which of the following laboratory findings should the nurse identify as the priority?
Correct Answer: A
Rationale: The correct answer is A: Blood glucose. In a newborn experiencing jitteriness, the priority is to assess blood glucose levels to rule out hypoglycemia. Newborns are at risk for hypoglycemia due to limited glycogen stores and high metabolic demands. Untreated hypoglycemia can lead to serious complications like seizures and brain damage.
Total bilirubin (choice
B) is important for assessing jaundice but is not the priority in this case. Hemoglobin (choice
C) and blood calcium (choice
D) are not typically the first considerations for jitteriness in a newborn.
Question 3 of 5
A nurse is admitting a client to the labor and delivery unit when the client states, 'My water just broke.' Which of the following interventions is the nurse's priority?
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. This is the priority because it assesses the well-being of the fetus immediately after the client's water breaks, ensuring timely detection of any fetal distress. Performing Nitrazine testing (
A) or checking cervical dilation (
C) can wait until after FHR monitoring. Assessing the fluid (
B) may be important but not as urgent as monitoring the FHR.
Question 4 of 5
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Report the client’s condition to the local health department. This action is important to ensure proper follow-up care, contact tracing, and prevention of HIV transmission. Administering penicillin G (
A) is not indicated for HIV, scheduling an annual pelvic exam (
B) is routine and not specific to the client's HIV status, and starting medication post-delivery (
C) delays necessary treatment.
Question 5 of 5
A nurse is caring for a client who is at 10 weeks of gestation. Which of the following findings should the nurse report to the provider?
Correct Answer: A
Rationale: The correct answer is A: Frequent vomiting with weight loss of 3 lb in 1 week. This finding could indicate hyperemesis gravidarum, a severe form of morning sickness that can lead to dehydration and malnutrition, posing risks to both the mother and fetus. Weight loss of 3 lb in 1 week is significant and requires immediate attention from the provider to prevent further complications.
Incorrect
Choices:
B: Reports of mood swings - Mood swings are common during pregnancy due to hormonal changes and typically do not pose a direct threat to the health of the mother or fetus.
C: Nosebleeds occurring approximately 3 times per week - While nosebleeds can occur during pregnancy due to increased blood flow, they are usually not concerning unless severe or accompanied by other symptoms.
D: Increased vaginal discharge - Increased vaginal discharge is a normal pregnancy symptom caused by hormonal changes and increased blood flow to the pelvic area. It is not typically a cause for immediate concern unless it is accompanied by other