ATI RN
Custom ATI Maternity Exam 2 Questions
Extract:
Client out of bed for the first time since delivery, passes a large amount of lochia
Question 1 of 5
A nurse is assisting a client out of bed for the first time since delivery. The client becomes frightened when she passes a large amount of lochia. Which of the following responses should the nurse make?
Correct Answer: Lochia can pool in the vagina while lying down and gush out upon standing, which is normal. The nurse should reassure the client that this is expected and not indicative of complications.
Rationale:
Extract:
Client who is 14 hr postpartum, breasts soft, fundus firm, slightly deviated to the right, moderate lochia rubra, temperature 37.7 C (100 F), pulse rate 88/min, respiratory rate 18/min
Question 2 of 5
A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft, fundus firm, slightly deviated to the right, moderate lochia rubra, temperature 37.7 C (100 F), pulse rate 88/min, respiratory rate 18/min. Which of the following actions should the nurse perform?
Correct Answer: A fundus deviated to the right suggests a full bladder, which can impede uterine contraction. Asking the client to empty her bladder is the priority to correct fundal position and prevent complications.
Rationale:
Extract:
Client with preeclampsia reporting epigastric pain and unresolved headache
Question 3 of 5
A nurse is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the RN immediately?
Correct Answer: Epigastric pain and unresolved headache in preeclampsia indicate severe disease, potentially progressing to eclampsia, requiring immediate reporting. The other findings are less urgent or expected.
Rationale:
Extract:
Client with unrelieved episiotomy pain 8 hr following delivery
Question 4 of 5
A nurse is caring for a client who has unrelieved episiotomy pain 8 hr following delivery. Which of the following actions should the nurse take?
Correct Answer: Applying an ice pack reduces swelling and pain at the episiotomy site within the first 24-48 hours. Warm sitz baths or heat are not recommended until later to avoid increasing swelling.
Rationale:
Extract:
Postpartum client with large amount of lochia rubra with several clots on perineal pad
Question 5 of 5
A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client’s perineal pad. Which of the following actions should the nurse take first?
Correct Answer: Checking the fundus is the priority to assess for uterine atony, a common cause of excessive lochia and clots. Massaging a soft fundus can promote contraction and reduce bleeding.
Rationale: