ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 of 5
A nurse is preparing to perform Leopold maneuvers on a client who is at 36 weeks of gestation. Identify the sequence of actions the nurse should take.
Correct Answer: A, B, C, D
Rationale:
To perform Leopold maneuvers on a client at 36 weeks gestation, the nurse should follow these steps:
A) Instruct the client to empty their bladder to provide better visualization and palpation of the uterus.
B) Position the client supine with knees flexed and place a small, rolled towel under one of their hips to enhance comfort and relaxation.
C) Palpate the fetal part positioned in the fundus to determine the presentation and position of the baby.
D) Palpate the fetal parts along both sides of the uterus to assess for consistency and location. These steps ensure accurate assessment of fetal position and presentation.
Choices E, F, and G are not applicable in the Leopold maneuvers sequence and do not contribute to the accurate assessment of the fetus.
Question 2 of 5
A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?
Correct Answer: A
Rationale: The correct answer is A: Swelling of the face. This is concerning as facial swelling can be a sign of preeclampsia, a serious condition in pregnancy characterized by high blood pressure and protein in the urine. The nurse should report this finding immediately to the provider for further evaluation and management to prevent complications for both the mother and the baby. Varicose veins in the calves (
B), nonpitting 1+ ankle edema (
C), and hyperpigmentation of the cheeks (
D) are common findings in pregnancy and do not typically require immediate reporting unless they are severe or causing significant discomfort.
Question 3 of 5
A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Decreased platelet count. In ITP, the immune system attacks and destroys platelets, leading to a low platelet count (thrombocytopenia). This can result in increased bleeding tendencies.
B: Increased ESR is not typically associated with ITP.
C: Decreased megakaryocytes is not expected in ITP as these are the precursors of platelets.
D: Increased WBC is not a characteristic finding in ITP.
Therefore, the nurse should expect a decreased platelet count in a client with postpartum ITP.
Question 4 of 5
A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply.)
Correct Answer: A,C,D
Rationale: The correct answer choices, A, C, and D, all contribute to an increased risk of postpartum hemorrhage. A, labor induction with oxytocin, can lead to uterine hyperstimulation, increasing the risk of postpartum hemorrhage. C, vacuum-assisted delivery, may cause trauma to the birth canal, leading to increased bleeding. D, history of uterine atony, indicates a previous inability of the uterus to contract effectively, which is a major risk factor for postpartum hemorrhage.
Therefore, these factors collectively place the client at a higher risk for postpartum hemorrhage.
Choices B and E are incorrect as they do not directly relate to the risk of postpartum hemorrhage.
Question 5 of 5
A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effects should the nurse include?
Correct Answer: A
Rationale: The correct answer is A: Breast tenderness. Clomiphene citrate is a medication commonly used to treat infertility by inducing ovulation. Breast tenderness is a common side effect due to the hormonal changes caused by the medication. This occurs because clomiphene citrate can increase estrogen levels, leading to breast discomfort. Tinnitus (
B), urinary frequency (
C), and chills (
D) are not typically associated with clomiphene citrate use. Tinnitus is more commonly linked to ototoxic medications, urinary frequency may be seen with diuretics, and chills are often indicative of an infection or allergic reaction.
Therefore, breast tenderness is the most relevant adverse effect to include in the teaching for a client experiencing infertility and taking clomiphene citrate.