Questions 49

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ATI Maternal Newborn 2023 Questions

Extract:

1. 08:00 - Client reported feeling pressure in the pelvic area. 2. 10:00 - Observed retraction of the fetal head against the maternal perineum. 3. 12:00 - Client reported increased discomfort; breathing exercises initiated. 4. 14:00 - Client's contractions have become more frequent and intense. Diagnostic Results: 1. Ultrasound: Healthy fetus in cephalic presentation. 2. Blood Test: Hemoglobin levels within normal range. 3. Urinalysis: No signs of infection or preeclampsia. 4. Fetal Heart Rate: Consistent with labor progression. Medical History: 1. First pregnancy, no complications. 2. No history of chronic illnesses. 3. No history of surgeries. 4. No known allergies. Vital Signs: 1. 08:00 - BP: 120/80, HR: 80 bpm, Temp: 98.6°F 2. 10:00 - BP: 122/82, HR: 82 bpm, Temp: 98.7°F 3. 12:00 - BP: 124/84, HR: 84 bpm, Temp: 98.8°F 4. 14:00 - BP: 126/86, HR: 86 bpm, Temp: 98.9°F Provider's Prescriptions: 1. Regular monitoring of vital signs. 2. Pain management as needed. 3. Encourage mobility as tolerated. 4. Regular monitoring of fetal heart rate. Physical Examination Results: 1. Cervix fully dilated. 2. Fetus in cephalic presentation. 3. Membranes ruptured. 4. Contractions regular and progressing. A 28-year-old female client is in the second stage of labor in the maternity ward.


Question 1 of 5

A nurse is caring for a client who is in the second stage of labor. The nurse observes retraction of the fetal head against the maternal perineum. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Correct Answer:

Rationale: The client is most likely experiencing normal labor progression. The retraction of the fetal head against the maternal perineum, regular and progressing contractions, and full dilation of the cervix are all signs of normal labor progression.

Extract:

A nurse is caring for a client who is at 34 weeks of gestation. The client is a 41-year-old Gravida 4 Para 3 with a history of gestational diabetes, eclampsia with a previous pregnancy, and chronic hypertension for 5 years. The client was admitted to the antepartum unit from the provider's office with elevated blood pressure, 3+ edema in the lower extremities, and 3+ proteinuria.


Question 2 of 5

What condition is the client most likely experiencing?

Correct Answer: A

Rationale: The client's symptoms of elevated blood pressure, 3+ edema, and 3+ proteinuria, combined with her history, indicate preeclampsia, requiring seizure precautions and monitoring of neurological status and liver function.

Extract:

A patient's lab results are as follows: BUN level is 8 mg/dL, Hemoglobin is 15 g/dL, Hematocrit is 47%, WBC count is 9,000/mm, Platelet count is 140,000/mm, Creatinine is 1.3 mg/dL, Bilirubin is 20 mg/dL, Aspartate aminotransferase (AST) is 36 units/L, and Alanine aminotransferase (ALT) is 40 units/L.


Question 3 of 5

What actions should be taken?

Correct Answer: C

Rationale: The bilirubin level of 20 mg/dL is significantly elevated (normal is 0.1-1.2 mg/dL), suggesting liver dysfunction or hemolysis, which requires further investigation. Reviewing daily logs helps monitor trends, but the provider should be notified of the bilirubin level.

Extract:

A nurse is assessing a client who is pregnant for preeclampsia.


Question 4 of 5

Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

Correct Answer: B

Rationale: Elevated blood pressure is a primary symptom of preeclampsia. If a pregnant client has high blood pressure, it should indicate to the nurse that the client requires further evaluation for this disorder.

Extract:

A nurse is monitoring a patient who is receiving magnesium sulfate to manage pre-eclampsia.


Question 5 of 5

Which of the following observations should the nurse report to the healthcare provider?

Correct Answer: D

Rationale: A urinary output of 40 mL in 2 hours is less than the normal range (at least 30 mL/hour). This could indicate kidney dysfunction, a serious complication of pre-eclampsia, and should be reported.

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