ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
Medical History:
• Gravida 2 Para 2
• Cesarean birth
• Deep vein thrombosis with previous pregnancy
• Preeclampsia
• BMI of 32
Question 1 of 5
A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
| Findings 24 hr later | Indication of worsening condition | Indication of improving condition |
|---|---|---|
| Increased warmth in the extremity | ||
| Tachycardia | ||
| Leukocytosis | ||
| Scant lochia rubra | ||
| Decreased extremity edema |
Correct Answer:
Rationale:
Correct
Answer:
Rationale:
1. Increased warmth in the extremity (Findings 24 hr later): Deep vein thrombosis can lead to increased warmth in the affected extremity due to inflammation.
2. Tachycardia (Indication of worsening condition): Tachycardia can indicate worsening condition or potential complications such as pulmonary embolism.
3. Leukocytosis (Indication of improving condition): Leukocytosis can indicate the body's response to infection or inflammation, which may be improving.
Other
Choices:
D: Scant lochia rubra - Not relevant to the assessment of deep vein thrombosis.
E: Decreased extremity edema - Edema is not a typical finding associated with deep vein thrombosis.
Extract:
“A nurse on an antepartum unit is caring for a client.
Exhibit1:
Nurses' Notes 0900:Client reports a small amount of bright red blood in their underwear upon
awakening. Client denies contractions or abdominal pain. External fetal monitor applied.
0930:Client passed large amount of bright red blood from vagina.
Denies pain Uterine tone soft and nontender to palpation.
contraction pattern, no contractions noted.
Fetal heart rate pattern: Fetal heart rate baseline 135/min.
Moderate variability. No decelerations noted.
Exhibit2:
Vital Signs 0900: Temperature 36.2°C (97.2° F) Pulse rate 78/min Respiratory rate 20/min Blood pressure
112/64 mm Hg Fetal heart rate 132/min Pulse rate 82/min Blood pressure 116/60 mm Hg Fetal heart
rate 160/min
Exhibit3:
Medical History. G4P3 30 weeks gestation Previous pregnancies delivered via cesarean section
Question 2 of 5
Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify it the intervention is indicated or contraindicated for the client.
| Potential Nursing Action | Indicated | Contraindicated | |
|---|---|---|---|
| Insert a large bore intravenous catheter. | |||
| Assess cervical dilation. | |||
| Weigh perineal pads. | |||
| Administer methotrexate. |
Correct Answer: A, C
Rationale: [1, 0, 1]
The correct answers are A and C (Weigh perineal pads).
- A large bore IV catheter may be necessary for rapid fluid resuscitation in emergencies, indicated for critically ill patients.
- Weighing perineal pads is essential to monitor postpartum bleeding, ensuring accurate assessment and timely intervention.
- Assessing cervical dilation (
B) is not typically a nursing action but a medical provider's task during labor.
- Administering methotrexate (
D) is a medical intervention for conditions like ectopic pregnancy, not within a nurse's scope.
Extract:
A nurse is caring for a newborn.
Exhibit 1
Medical History
1600:
Apgar score 9 at 1 min and 9 at 5 min
Birth weight 4,706 g (10 lb 6 oz)
Gestational age 40 weeks
Difficult vaginal birth with shoulder dystocia. Exhibit 2
Nurses' Notes
1700:
Newborn is active and moves all extremities except for right arm. No spontaneous movement of
the right arm noted. Right arm remains at side during Moro reflex. Exhibit 3
Physical Examination
1830:
Absent Moro reflex noted in right arm.
Right shoulder and arm are internally rotated and adducted. Elbow extended. Forearm pronated
with wrist and fingers flexed. Diagnosis: Brachial plexus injury resulting in Erb-Duchenne (Erb's
palsy) paralysis.
Question 3 of 5
Which of the following actions should the nurse plan to implement? For each potential nursing action, click to specify if the intervention is indicated or contraindicated for the newborn.
| Potential Nursing Action | Indicated | Contraindicated |
|---|---|---|
| Educate the parents to begin range of motion exercises on the affected arm after 1 week. | ||
| Assess for grasp reflex in the affected extremity. | ||
| Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt. | ||
| Instruct parents to limit physical handling for 2 weeks. |
Correct Answer:
Rationale:
Correct
Answer:
Rationale:
- Educate the parents to begin range of motion exercises on the affected arm after 1 week is indicated as it promotes joint mobility.
- Assess for grasp reflex in the affected extremity is contraindicated as it can cause discomfort and potential harm.
- Immobilizing the arm across the abdomen is contraindicated as it can restrict circulation and hinder development.
- Instructing parents to limit physical handling for 2 weeks is indicated to prevent excessive stress on the affected arm.
Extract:
A nurse in a clinic is caring for a 16-year-old adolescent.
Exhibit 1
History and Physical
Adolescent is sexually active with two current partners.
IUD in place
Reports not using condoms during sexual activity.
History of type 1 diabetes mellitus”
Question 4 of 5
Which of the following conditions should the nurse identify as being consistent with the adolescent's assessment findings? For each finding click to specify if the assessment findings are consistent with trichomoniasis, gonorrhea, or candidiasis. Each finding may support more than one disease process.
| Assessment Findings | Trichomoniasis | Gonorrhea | Candidiasis |
|---|---|---|---|
| Abdominal pain. | |||
| Greenish discharge. | |||
| Diabetes. | |||
| Pain on urination. | |||
| Absence of condom. |
Correct Answer: B, D
Rationale: Sure, here is the detailed explanation:
- Trichomoniasis: Trichomoniasis typically presents with greenish discharge but not pain on urination.
- Gonorrhea: Gonorrhea can cause both greenish discharge and pain on urination.
- Candidiasis: Candidiasis does not typically present with greenish discharge or pain on urination.
Therefore, based on the assessment findings provided:
- Abdominal pain: Not specific to any of the given conditions.
- Greenish discharge: Consistent with both gonorrhea and trichomoniasis.
- Diabetes: Not directly related to the symptoms provided.
- Pain on urination: Consistent with gonorrhea.
- Absence of condom: Not relevant to the symptoms provided.
The correct answer is B, D as greenish discharge and pain on urination are consistent with both gonorrhea and trichomoniasis, making them the most likely conditions based on the assessment findings.
Extract:
A nurse is caring for a client who is experiencing a postpartum hemorrhage and has a new prescription for misoprostol.
Exhibit 2: Medical History
Preeclampsia
Cesarean birth of viable twin male newborns
Question 5 of 5
The nurse is assessing the client 30 min later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
| Findings 30 min later | Unrelated to diagnosis | Indication Of potential improvement | Indication of Potential worsening condition |
|---|---|---|---|
| Fundus at level of umbilicus | |||
| Cloudy urine | |||
| Blood pressure 80/50 mm Hg | |||
| Moderate lochia rubra | |||
| Thready pulse | |||
| Fundus firm to palpation |
Correct Answer:
Rationale:
Correct
Answer:
Rationale:
- Fundus at the level of the umbilicus is an indication of potential improvement as it indicates proper involution of the uterus.
- Cloudy urine is unrelated to the diagnosis and may indicate other issues like urinary tract infection.
- Blood pressure of 80/50 mm Hg is an indication of potential worsening condition as it is hypotensive.
- Moderate lochia rubra is also an indication of potential worsening condition as it may indicate excessive bleeding.
- Thready pulse is unrelated to the diagnosis.
- Fundus firm to palpation is an indication of potential improvement as it indicates proper uterine contraction and involution.