ATI RN
ATI RN Maternal Newborn Latest Update. Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is hypotensive following the administration of epidural anesthesia. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Turn the client to a side-lying position. This action helps improve venous return and cardiac output, which can help increase blood pressure in a hypotensive client. Placing the client in a side-lying position can prevent compression of the vena cava by the uterus, which may occur with epidural anesthesia. Options B, C, and D are incorrect. Applying oxygen via nasal cannula, massaging the fundus, and assisting the client to empty their bladder are not the priority actions in addressing hypotension following epidural anesthesia. Oxygen administration may be important, but positioning the client is the priority in this situation.
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: [,(0,0,1),(0,0,0),(0,0,0)]
Correct Answer: A, C
Rationale:
A: Inserting a large bore intravenous catheter is indicated for administering medications or fluids rapidly in emergency situations.
C: Weighing perineal pads is indicated to monitor postpartum hemorrhage.
Assessing cervical dilation (
B) is not necessary in this scenario. Administering methotrexate (
D) is not a nursing action.
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 3 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: - A, D, E are correct, B, C are incorrect)
Rationale: A - Fundus at level of umbilicus indicates proper uterine involution. D - Moderate lochia rubra is expected postpartum. E - Thready pulse may indicate hypovolemia, requiring intervention. B - Cloudy urine may indicate infection, not improvement. C - Low blood pressure may indicate hypovolemic shock, a worsening condition.
Extract:
Question 4 of 5
A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique. Which of the following information should the nurse include?
Correct Answer: D
Rationale: The correct answer is D because a dark red appearance at the end of the baby's penis could indicate infection or poor circulation, which are concerns post-circumcision. The nurse should instruct parents to notify the provider immediately if they observe this change to ensure prompt assessment and treatment.
Choice A is incorrect as the Plastibell is typically removed within 5-8 days, not 4 hours post-procedure.
Choice B is incorrect because a snug diaper can cause discomfort and interfere with healing.
Choice C is incorrect as yellow exudate is not a typical finding at the surgical site in 24 hours post-circumcision.
Question 5 of 5
A nurse is reviewing laboratory findings for a client who is at 20 weeks of gestation. Which of the following findings should the nurse report to the provider?
Correct Answer: D
Rationale: The correct answer is D: Fasting blood glucose 180 mg/dL (74 to 106 mg/dL). High blood glucose levels during pregnancy can indicate gestational diabetes, which poses risks to both the mother and the baby. The nurse should report this finding to the provider for further evaluation and management.
Choice A (Hematocrit 37%): Falls within the normal range for pregnancy and does not require immediate reporting.
Choice B (Creatinine 0.9 mg/dL): Within the normal range and does not indicate a concerning issue at this time.
Choice C (WBC count 11,000/mm3): Slightly elevated, but can be a normal physiological response during pregnancy and does not necessarily warrant immediate reporting.
In summary, the correct answer is D as it signifies a potential health concern that requires further assessment.
Choices A, B, and C are within normal ranges for pregnancy and do not pose immediate risks.