ATI RN
RN ATI Maternal Newborn 2023 with NGN Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is in labor and reports increasing rectal pressure. They are experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that their cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?
Correct Answer: D
Rationale: The correct answer is D: Descent. At 9 cm dilation, the client is in the second stage of labor, which consists of the descent and birth of the baby. Increasing rectal pressure indicates fetal descent and impending birth. Contractions 2-3 min apart lasting 80-90 seconds are characteristic of the active phase of the second stage of labor. The passive descent phase occurs earlier when the cervix is not fully dilated. The early phase is part of the first stage of labor. Active labor typically begins when the cervix is around 6 cm dilated.
Therefore, D is the correct choice as it aligns with the client's symptoms and stage of labor progression.
Question 2 of 5
A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
Correct Answer: B
Rationale: The correct answer is B: Temperature. During an amniotomy, there is a risk of infection due to the introduction of bacteria into the amniotic fluid. Monitoring the client's temperature is crucial as an elevated temperature could indicate infection, which can be life-threatening for both the mother and the fetus. O2 saturation (
A), blood pressure (
C), and urinary output (
D) are important assessments but not the priority in this situation. O2 saturation is typically monitored continuously during labor, blood pressure can fluctuate during labor but is not directly impacted by amniotomy, and urinary output is important for assessing hydration status but does not take precedence over monitoring for infection.
Question 3 of 5
A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: A
Rationale: The correct answer is A. By stating she will eat foods that taste good instead of balancing meals, the client demonstrates understanding of the need to prioritize eating to manage hyperemesis gravidarum. This choice indicates she recognizes the importance of maintaining adequate nutrition despite food aversions.
Choice B is incorrect as avoiding bedtime snacks may worsen nausea.
Choice C is incorrect as caffeine in tea can exacerbate nausea.
Choice D is incorrect as dairy products are important for calcium and protein intake during pregnancy.
Extract:
A nurse is caring for a postpartum client in an outpatient setting
Exhibit1:
History and Physical
G1P1, spontaneous vaginal delivery with median episiotomy at 39 weeks of gestation.
Newborn 4,508 g (9 lb 15 oz), APGARs: 8 at 1 min, 9 at 5 min
group B streptococcus 8-hemolytic: positive (negative)
Received 2 doses of Intravenous penicillin G while in labor”
Question 4 of 5
complete the following sentence by using the lists of options. The client is at highest risk for developing ---evidenced by the client's ---
| Endometritis. |
| Mastitis. |
| Postpartum hemorrhage. |
| Group B streptococcus positive status. |
| Spontaneous vaginal delivery. |
| Median episiotomy. |
Correct Answer: A
Rationale:
Correct Answer: A
Rationale:
1. Endometritis is an infection of the uterine lining, commonly occurring post-delivery.
2. The client's risk for endometritis increases due to factors like prolonged labor, multiple vaginal exams, and retained placental fragments.
3. The client's condition or symptoms may include fever, uterine tenderness, foul-smelling lochia.
4. The other options (B-F) are not directly related to the highest risk for developing endometritis post-delivery.
Extract:
Question 5 of 5
A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?
Correct Answer: A
Rationale: The correct answer is A: You should take the medication within 72 hours following unprotected sexual intercourse. Levonorgestrel is most effective when taken within 72 hours after unprotected sex to prevent pregnancy. This timing is crucial for its efficacy.
Choice B is incorrect because levonorgestrel can be used in combination with oral contraceptives if needed.
Choice C is incorrect as the absence of a period does not always indicate pregnancy, and a pregnancy test may not be necessary.
Choice D is incorrect because levonorgestrel is effective for a shorter duration, not 14 days.