ATI RN
ATI Maternal Newborn Proctored Exam Latest Update Questions
Extract:
Question 1 of 5
A nurse is caring for a child with Wilms' tumor. The parents ask why the sign 'Do not palpate the abdomen' has to be placed on their child's bed. Which of the following is the correct response by the nurse?
Correct Answer: C
Rationale: The correct response is C: Palpation of the abdomen could result in some of the tumor cells breaking loose, causing it to spread. Palpating the abdomen in a child with Wilms' tumor can potentially lead to the dissemination of tumor cells into surrounding tissues and blood vessels, increasing the risk of metastasis. This precaution is crucial to prevent the spread of cancer cells and to contain the tumor within the kidney.
Choices A, B, and D are incorrect as they do not address the specific risk associated with manipulating the abdomen in a child with Wilms' tumor. Option A focuses solely on pain, which is not the primary concern in this case. Option B is inaccurate as palpation does not cause tumor growth. Option D is irrelevant to the potential consequences of abdominal manipulation in this context.
Question 2 of 5
Two hours after delivery the nurse assesses the client and documents that the fundus is soft, boggy, above the level of the umbilicus, and displaced to the right side. The nurse encourages the client to void. Which is the rationale for this nursing action?
Correct Answer: A
Rationale:
Correct Answer: A
Rationale:
1. After delivery, the uterus should be firm and midline to facilitate uterine contractions and prevent excessive bleeding.
2. A soft, boggy uterus may indicate uterine atony, which can lead to postpartum hemorrhage.
3. A full bladder can impede uterine contractions by displacing the uterus and preventing it from contracting effectively.
4. By encouraging the client to void, the nurse helps ensure that the bladder is not obstructing the uterus, promoting proper uterine involution and preventing complications.
Summary of Incorrect
Choices:
B: Overdistended bladder pressing on episiotomy may cause dehiscence, but this is not the primary concern in this scenario.
C: Bladder distention causing urinary stasis and infection is a potential complication, but it is not directly related to uterine contractions.
D: Massaging the fundus can be helpful but addressing the full bladder is a priority
Question 3 of 5
Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow?
Correct Answer: D
Rationale: The correct answer is D because it accurately describes the progression of lochia flow after delivery. Lochia starts as bright red (lochia rubra) on days 1-3, transitions to pinkish brown (lochia serosa) on days 4-9, and finally becomes creamy white (lochia alba) from days 10-21. This information is crucial for the postpartum client to understand what is normal regarding lochia color and duration.
Choice A is incorrect as it does not provide the correct timeline of color changes.
Choices B and C are incorrect because they focus on abnormal findings rather than the normal progression of lochia.
Question 4 of 5
A woman in the first trimester comes to the clinic with vaginal bleeding. The physician determines that the fetus has died and that the placenta, fetus, and tissues still remain in the uterus. How should the findings be documented?
Correct Answer: C
Rationale: The correct answer is C: Missed abortion. In a missed abortion, the fetus has died but the products of conception are retained in the uterus. This scenario matches the description given in the question where the physician finds the fetus has died but the tissues remain. A missed abortion typically presents with vaginal bleeding and the absence of fetal heart tones. Other choices are incorrect because: A: Complete abortion would indicate that all products of conception have been expelled. B: Stillborn abortion is not a recognized medical term. D: Incomplete abortion would involve partial expulsion of products of conception.
Question 5 of 5
A client is admitted to the hospital with severe pregnancy-induced hypertension (PIH). The physician orders magnesium sulfate. Which nursing intervention is important when administering this drug?
Correct Answer: A
Rationale: The correct answer is A: Assess blood pressure and respiratory rate every fifteen minutes when administering magnesium sulfate to a client with severe PIH. This is crucial because magnesium sulfate is a potent medication that can cause respiratory depression and hypotension as side effects. Monitoring these parameters frequently allows early detection of any adverse reactions, enabling prompt intervention. Option B is incorrect as monitoring blood glucose levels is not directly related to magnesium sulfate administration. Option C is incorrect as orthostatic hypotension is not a common side effect of magnesium sulfate. Option D is incorrect as observing for premature labor is not relevant to the administration of magnesium sulfate for PIH.