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 reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?
Correct Answer: A
Rationale: The correct answer is A: Oligohydramnios. Electronic fetal monitoring is indicated for assessing fetal well-being in pregnancies with conditions that may compromise fetal oxygenation, such as oligohydramnios. Oligohydramnios is a condition where there is an insufficient amount of amniotic fluid around the fetus, which can lead to fetal distress. Electronic fetal monitoring helps track the fetal heart rate and uterine contractions to detect signs of distress. Hyperemesis gravidarum (
B), leukorrhea (
C), and periodic tingling of the fingers (
D) are not indications for fetal monitoring as they do not directly impact fetal well-being.
Question 3 of 5
A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Decreased platelet count. In idiopathic thrombocytopenic purpura (ITP), there is a decrease in platelet count due to immune-mediated destruction of platelets. This can lead to bleeding tendencies. Other choices are incorrect because in ITP, there is no significant change in ESR (
B), megakaryocytes may be increased or normal (
C), and WBC count is usually normal or slightly elevated (
D).
Question 4 of 5
A nurse who is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?
Correct Answer: C
Rationale: The correct answer is C: Administer Rh(0) Immune globulin. This is the priority intervention as the client is Rh-negative and has just undergone an invasive procedure like amniocentesis, which carries a risk of fetal-maternal blood transfer. Administering Rh(0) Immune globulin helps prevent the development of Rh incompatibility, which could lead to hemolytic disease in the newborn. Checking the client's temperature (
A) and monitoring the FHR (
D) are important but not the priority immediately post-procedure. Observing for uterine contractions (
B) is important but not the priority for an Rh-negative client after amniocentesis.
Question 5 of 5
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on bed rest. It is essential to maintain the client on bed rest to prevent further complications and to reduce the risk of dislodging the clot. Moving the affected leg could potentially dislodge the clot, leading to serious consequences such as pulmonary embolism. Administering aspirin for pain (choice
A) is not appropriate as it can increase the risk of bleeding, especially in a patient receiving heparin. Massaging the affected leg (choice
C) can also dislodge the clot and should be avoided. Applying cold compresses (choice
D) can potentially exacerbate the situation by causing vasoconstriction and increasing the risk of clot formation.