ATI RN
ATI Maternal Newborn Final Exam moitoso Questions
Extract:
Client in fourth stage of labor, BP 144/92, pulse 99, respirations 17, pulse ox 97%, temperature 100.4 F, pain score 1/10.
Question 1 of 5
A nurse is caring for a client in the fourth stage of labor after a vaginal delivery. History and Physical: BP: 144/92 mmHg. Pulse: 99 bpm. Respirations: 17/min. Pulse Ox: 97%. Temperature: 100.4 F (38.0 C). Pain score: 1/10. The nurse should first address the client's ____________ (assessment finding), followed by the client's ____________ (assessment finding).
Correct Answer: A
Rationale: Elevated BP (144/92 mmHg) is a priority due to potential preeclampsia, followed by temperature (100.4°F) indicating possible infection.
Extract:
Client 2 hr postpartum, received spinal anesthesia for cesarean birth.
Question 2 of 5
A nurse is assessing a client who is 2 hr postpartum and received spinal anesthesia for a cesarean birth. Which of the following findings requires immediate intervention by the nurse?
Correct Answer: A
Rationale: A respiratory rate of 10/min suggests possible respiratory depression from spinal anesthesia, requiring immediate intervention.
Extract:
Client receiving intravenous magnesium sulfate for preeclampsia.
Question 3 of 5
A nurse is caring for a client who is receiving intravenous magnesium sulfate for preeclampsia. Which assessment finding would alert the nurse to suspect magnesium toxicity?
Correct Answer: D
Rationale: Absent deep tendon reflexes indicate magnesium toxicity, as high magnesium levels depress neuromuscular function, requiring immediate intervention.
Extract:
Client being assessed for postpartum infection.
Question 4 of 5
A nurse is assessing a client for postpartum infection. Which of the following findings should indicate to the nurse that the client requires further evaluation for endometritis?
Correct Answer: A
Rationale: Pelvic pain and fatigue suggest endometritis, requiring further evaluation for uterine infection.
Extract:
Client in labor with external fetal monitoring, FHR slows at contraction start, nadir at contraction peak, returns to baseline at contraction end.
Question 5 of 5
A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart rate begins to slow at the start of a contraction and the nadir is at the same time as the peak of the contraction. The FHR returns to the FHR baseline at the same time that the contraction ends. The nurse should document this finding as which of the following?
Correct Answer: C
Rationale: Early decelerations mirror contractions, with nadir at the peak, typically benign and due to fetal head compression.