ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 of 5
A nurse is collecting data from a client who is at 30 weeks of gestation. Which of the following findings should the nurse identify as a manifestation of pyelonephritis?
Correct Answer: B
Rationale: The correct answer is B: Flank pain. Pyelonephritis is a kidney infection that commonly presents with symptoms such as flank pain, fever, chills, and dysuria. Flank pain is a key manifestation due to the inflammation of the kidneys. Epigastric discomfort (choice
A) is more indicative of issues related to the stomach or upper abdomen. Temperature elevation (choice
C) is a common sign of infection but alone is not specific to pyelonephritis. Abdominal cramping (choice
D) is more likely related to gastrointestinal issues. In summary, flank pain is specific to pyelonephritis, making it the correct choice in this scenario.
Question 2 of 5
A nurse is planning care for a client who is 1 hr postpartum and has peripartum cardiomyopathy. Which of the following actions should the nurse plan to take?
Correct Answer: B
Rationale: The correct answer is B: Assess blood pressure twice daily. Postpartum peripartum cardiomyopathy can lead to heart failure, making monitoring blood pressure crucial for early detection of worsening condition. Assessing blood pressure twice daily allows for timely intervention if hypertension or hypotension occurs. Option A, misoprostol, is used for preventing gastric ulcers, not related to peripartum cardiomyopathy. Option C, restricting oral fluid intake, is not appropriate as adequate hydration is essential postpartum. Option D, administering an IV bolus of lactated Ringer's, may not be necessary unless specifically indicated for the client's condition.
Extract:
A nurse is assessing a postpartum client who delivered vaginally 8 hr ago.
Exhibit 1 - Nurses' Notes: 0700
Breasts soft, nipples intact. Uterus palpated firm, midline, and at the level of the umbilicus.
Moderate amount of lochia rubra. Episiotomy site well approximated with mild edema and
ecchymosis. Client reports pain as 2 on a scale of 0 to 10. Able to void spontaneously; no bladder
distention. Deep tendon reflexes 1+. Peripheral edema 2+ in bilateral lower extremities.
Exhibit 2 - Nurses' Notes: 1100
Breasts soft, nipples intact. Uterus palpated soft with lateral deviation and 1 cm above the
umbilicus. Large amount of lochia rubra. Episiotomy site well approximated with mild edema
and ecchymosis. Client reports pain as 3 on a scale of 0 to 10. Deep tendon reflexes 1+.
Peripheral edema 2+ in bilateral lower extremities.
Question 3 of 5
Select the 3 findings that require immediate follow-up.
Correct Answer: A,B,C
Rationale: The correct choices for immediate follow-up are A, B, and C. A lateral deviation of the uterus could indicate a potential complication like uterine prolapse. Deep tendon reflexes 1+ could suggest a neurological issue or electrolyte imbalance. A pain rating of 3 on a scale of 0 to 10 (increased) requires further assessment to determine the cause and provide appropriate treatment.
Choices D, E, F, and G are not as urgent. Peripheral edema 2+ bilateral lower extremities could be indicative of fluid retention, which may need monitoring but not immediate intervention. Soft uterine tone may be expected postpartum, and a large amount of lochia rubra could be normal after birth. A blood pressure of 136/86 mm Hg is slightly elevated but not critically high, so it may require monitoring but not immediate follow-up.
Extract:
Question 4 of 5
A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Determine respiratory function. The first priority in an unresponsive client is to assess their airway, breathing, and circulation (ABCs). Respiratory function is crucial for oxygenation and maintaining vital signs. If a client is unresponsive, assessing their respiratory status is essential to determine if they are breathing or in need of immediate intervention like CPR. Increasing IV fluid rate (
B) is not the priority as the client's respiratory status needs to be assessed first. Accessing emergency medications (
C) is not the immediate priority as the client's airway and breathing take precedence. Collecting a blood sample (
D) may be necessary later but is not the first action in an unresponsive client.
Question 5 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: B
Rationale: The correct answer is B: Active phase of labor. At 9 cm dilation, the client is transitioning from the latent phase to the active phase. In the active phase, the cervix typically dilates from 6 to 10 cm. The client's contractions are close together and long-lasting, indicating active labor. Rectal pressure is common during the active phase as the baby descends further. The passive descent (
A) phase occurs later in labor when the cervix is fully dilated, and the client is ready to push. Early phase (
C) is characterized by slow cervical dilation from 0 to 6 cm. Descent (
D) phase is not a recognized phase of labor.