ATI RN
RN ATI Maternal Newborn 2023 with NGN Questions
Extract:
Question 1 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.
Question 2 of 5
A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first?
Correct Answer: A
Rationale: The correct answer is A. Abdominal cramping in early pregnancy could be a sign of an ectopic pregnancy or miscarriage, both of which are urgent and potentially life-threatening conditions. The nurse should prioritize assessing this client to rule out any serious complications.
Choice B is not as urgent as choice A because tingling and numbness in the hand are likely due to musculoskeletal or nerve compression issues, which are not immediately life-threatening.
Choice C, constipation, is a common issue in pregnancy and is not typically considered an urgent concern unless accompanied by severe symptoms like abdominal pain or bleeding.
Choice D, frequent bloody noses, is not typically an urgent concern in early pregnancy unless it is accompanied by other severe symptoms like dizziness or excessive bleeding.
In summary, the nurse should prioritize assessing the client experiencing abdominal cramping at 11 weeks of gestation due to the potential seriousness of this symptom in early pregnancy.
Question 3 of 5
A nurse is caring for a client who is to receive oxytocin to augment their labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
Correct Answer: A
Rationale: The correct answer is A: Late decelerations. Late decelerations indicate uteroplacental insufficiency, meaning the baby is not getting enough oxygen during contractions. Administering oxytocin, which can further stress the baby by increasing contractions, can worsen the situation. Late decelerations are a sign of fetal distress and require immediate intervention.
B: Moderate variability of the FHR is a normal finding and does not contraindicate the initiation of oxytocin.
C: Cessation of uterine dilation would suggest a potential issue with labor progress but does not directly contraindicate oxytocin.
D: Prolonged active phase of labor may warrant oxytocin to augment contractions but is not a contraindication itself.
Question 4 of 5
A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Verify the newborn's identification. This should be done first to ensure the right baby is receiving care. Confirming the identity helps prevent errors in medication administration and procedures. Checking the identification is crucial for patient safety. The other options are not the first priority in this scenario. A: Confirming the Apgar score can wait until after ensuring the correct baby is being cared for. C: Administering vitamin K is important, but verifying identification takes precedence. D: Determining obstetrical risk factors can be done later once the baby's identity is confirmed.
Question 5 of 5
A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?
Correct Answer: C
Rationale:
Correct
Answer: C - Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution.
Rationale: Continuous monitoring of blood pressure is crucial after administering epidural anesthesia to detect any potential hypotension, a common side effect. This frequent monitoring allows for prompt intervention if hypotension occurs, ensuring the client's safety. It is essential to closely monitor the client's vital signs, particularly blood pressure, to prevent complications such as decreased placental perfusion and fetal distress.
Summary:
A: Placing the client in a supine position for 30 min following the first dose of anesthetic solution is not recommended as it can lead to aortocaval compression and compromise blood flow to the fetus.
B: Administering dextrose 5% in water prior to the first dose of anesthetic solution is not necessary for epidural anesthesia.
D: Ensuring the client has been NPO 4 hr prior to the placement of the epidural is