ATI RN
Custom ATI Maternity Exam 2 Questions
Extract:
Client with unrelieved episiotomy pain 8 hr following delivery
Question 1 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:
Client in the first stage of labor with umbilical cord protruding from the vagina
Question 2 of 5
A nurse is assisting with the care of a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse take first?
Correct Answer: Placing the client in a knee-chest or Trendelenburg position is the priority to relieve pressure on the prolapsed cord, restoring blood flow to the fetus and preventing hypoxia. This addresses the immediate risk of cord compression.
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 3 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:
Postpartum client with large amount of lochia rubra with several clots on perineal pad
Question 4 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:
Extract:
Client who is postpartum
Question 5 of 5
A nurse is collecting data from a client who is postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?
Correct Answer: A temperature of 100.4°F for two days suggests a possible infection, such as endometritis, requiring immediate attention. The other findings are normal or expected postpartum.
Rationale: