ATI RN
RN ATI Maternal Proctored Exam 2023-2024 with NGN Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?
Correct Answer: A
Rationale:
Correct Answer: A - Apply a moist, warm compress to the perineum.
Rationale: Applying a moist, warm compress helps to reduce swelling, promote healing, and provide comfort to the client with a fourth-degree laceration. The warmth improves blood circulation to the area, aiding in the healing process. It also helps to relieve pain and discomfort.
Summary of other choices:
B: Providing a cool sitz bath may be too cold and uncomfortable for the client with a fourth-degree laceration.
C: Administering methylergonovine is not indicated for a perineal laceration and may cause adverse effects such as hypertension.
D: Applying povidone-iodine to the perineum can be too harsh and may delay healing of the laceration. It is not recommended for this situation.
Question 2 of 5
A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?
Correct Answer: D
Rationale: The correct answer is D: Third-degree perineal laceration. This type of laceration extends through the vaginal mucosa, perineal muscles, and anal sphincter, making the use of a suppository contraindicated due to the risk of infection and increased pain. Vaginal candidiasis (choice
A) does not directly impact the use of a suppository. Abdominal distention (choice
B) can be addressed by using a suppository. Afterpains (choice
C) are normal postpartum contractions and do not contraindicate the use of a suppository. In summary, the presence of a third-degree perineal laceration poses a significant risk if a suppository is used, making it the correct answer.
Question 3 of 5
A nurse is assessing a client who is 1 hr postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct action for the nurse to take first in this situation is to massage the client's fundus. This is because excessive vaginal bleeding postpartum can be a sign of uterine atony, which is the most common cause of postpartum hemorrhage. Massaging the fundus helps to stimulate uterine contractions and can help control bleeding. Administering oxytocin (choice
B) can also help with uterine contractions, but massaging the fundus should be done first to assess the situation. Emptying the client's bladder (choice
C) can help relieve pressure on the uterus, but it is not the priority in this situation. Providing oxygen (choice
D) is not indicated for excessive vaginal bleeding unless the client is showing signs of hypoxia.
Question 4 of 5
A nurse is assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect?
Correct Answer: C
Rationale: The correct answer is C: Uterine tenderness. Endometritis is an infection of the uterine lining, typically occurring postpartum. Uterine tenderness is a common finding due to inflammation and infection. A: Temperature of 37.4°C is within normal range. B: WBC count of 9,000/mm3 is normal. D: Scant lochia would not be expected with endometritis as it typically presents with increased or foul-smelling lochia.
Question 5 of 5
A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?
Correct Answer: B
Rationale: The correct answer is B: Transmission can occur via the saliva and urine of the newborn. Maternal cytomegalovirus (CMV) is commonly transmitted to the newborn through infected bodily fluids such as saliva and urine. This is important for the newly licensed nurses to understand as it highlights the need for strict infection control practices to prevent transmission to vulnerable infants.
Choice A is incorrect because acyclovir is not used for prophylactic treatment of CMV.
Choice C is incorrect as CMV typically does not present with visible lesions on the mother's genitalia.
Choice D is incorrect as airborne precautions are not necessary for newborns with CMV. It is crucial for nurses to focus on understanding the modes of transmission and prevention strategies for CMV to provide optimal care for both the mother and the newborn.