ATI LPN
ATI PN Maternal Newborn Rn X1 Questions
Extract:
client, 14 hr postpartum, boggy fundus, large lochia rubra
Question 1 of 5
A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft, fundus boggy 4 fingerbreadths above the umbilicus and deviated to the right, large lochia rubra, temperature 37.7°C (100°F), pulse rate 86/min, respiratory rate 18/min. Which of the following actions should the nurse perform?
Correct Answer: A
Rationale: A full bladder can displace the uterus, causing a boggy fundus and increased bleeding; emptying the bladder is the priority.
Question 2 of 5
A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft, fundus boggy 4 fingerbreadths above the umbilicus and deviated to the right, large 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
Rationale: Emptying the bladder corrects uterine displacement, addressing the boggy fundus and excessive lochia.
Extract:
client, 32 weeks gestation, in labor
Question 3 of 5
A nurse is assisting with the care of a client who is at 32 weeks of gestation and in labor. The client asks the nurse, 'Will my baby be okay?' Which of the following responses should the nurse make?
Correct Answer: C
Rationale: This response acknowledges the client’s fear and encourages discussion, providing emotional support.
Extract:
client, active labor, variable decelerations of FHR
Question 4 of 5
A nurse is assisting in the care of a client who is in active labor. The nurse notes variable decelerations of the FHR. The nurse should identify which of the following as a cause of variable decelerations?
Correct Answer: C
Rationale: Variable decelerations are caused by umbilical cord compression, reducing fetal blood flow.
Extract:
client, 4 hr postpartum, lochia rubra, fundus midline and firm
Question 5 of 5
A nurse is caring for a client who is 4 hr postpartum. The nurse finds a small amount of lochia rubra on the client's perineal pad. The fundus is midline and firm at one fingerbreadth above the umbilicus. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Checking for blood under the buttock ensures no hidden bleeding, as pads may not capture all lochia, despite a firm, midline fundus.