Questions 23

ATI RN

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Custom ATI Maternity Exam 2 Questions

Extract:

Client who is 14 hr postpartum, breasts soft, fundus firm, slightly deviated to the right, moderate lochia rubra, temperature 37.7 C (100 F), pulse rate 88/min, respiratory rate 18/min


Question 1 of 5

A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft, fundus firm, slightly deviated to the right, moderate lochia rubra, temperature 37.7 C (100 F), pulse rate 88/min, respiratory rate 18/min. Which of the following actions should the nurse perform?

Correct Answer: A fundus deviated to the right suggests a full bladder, which can impede uterine contraction. Asking the client to empty her bladder is the priority to correct fundal position and prevent complications.

Rationale:

Extract:

Client following a cesarean birth, reports being hungry


Question 2 of 5

A nurse is caring for a client following a cesarean birth. The client tells the nurse that she is hungry. Which of the following actions should the nurse take first?

Correct Answer: Auscultating the abdomen for bowel sounds is the priority to confirm the return of peristalsis post-cesarean, ensuring the client can tolerate oral intake without complications.

Rationale:

Extract:

Client who is 14 hr postpartum, breasts soft, fundus firm, slightly deviated to the right, moderate lochia rubra, temperature 37.7 C (100 F), pulse rate 88/min, respiratory rate 18/min


Question 3 of 5

A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft, fundus firm, slightly deviated to the right, moderate lochia rubra, temperature 37.7 C (100 F), pulse rate 88/min, respiratory rate 18/min. Which of the following actions should the nurse perform?

Correct Answer: A fundus deviated to the right suggests a full bladder, which can impede uterine contraction. Asking the client to empty her bladder is the priority to correct fundal position and prevent complications.

Rationale:

Extract:

Client at 39 weeks of gestation with heavy vaginal bleeding


Question 4 of 5

A nurse is assisting with the admission of a client who is at 39 weeks of gestation and has heavy vaginal bleeding. Which of the following actions should the nurse take?

Correct Answer: Heavy vaginal bleeding at 39 weeks suggests conditions like placental abruption or placenta previa, necessitating preparation for a cesarean birth to ensure maternal and fetal safety.

Rationale:

Extract:

Client in the first stage of labor with umbilical cord protruding from the vagina


Question 5 of 5

A nurse is assisting with the care of a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse take first?

Correct Answer: Placing the client in a knee-chest or Trendelenburg position is the priority to relieve pressure on the prolapsed cord, restoring blood flow to the fetus and preventing hypoxia. This addresses the immediate risk of cord compression.

Rationale:

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