ATI RN
RN ATI Maternal Proctored Exam 2023-2024 with NGN Questions
Extract:
Question 1 of 5
A nurse is providing teaching about increasing dietary fiber to an antepartum client who reports constipation. Which of the following food selections has the highest fiber content per cup?
Correct Answer: D
Rationale: The correct answer is D: Lentils. Lentils have the highest fiber content per cup compared to the other options. Lentils contain around 15.6 grams of fiber per cooked cup, making them an excellent choice for alleviating constipation. Oatmeal, cabbage, and asparagus have lower fiber content per cup compared to lentils. Oatmeal typically contains around 4 grams of fiber per cup, while cabbage and asparagus have approximately 2-4 grams of fiber per cup.
Therefore, lentils are the best choice for increasing dietary fiber and promoting bowel regularity in the antepartum client.
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 2 of 5
Select the 3 findings that require immediate follow-up.
Correct Answer: A,B,C
Rationale: The correct findings that require immediate follow-up are A, B, and C.
A: Lateral deviation of the uterus indicates a potential complication like uterine atony or retained placental fragments.
B: Deep tendon reflexes of 1+ could indicate hyporeflexia, which may be a sign of neurological issues.
C: Pain rating of 3 on a scale of 0 to 10 (increased) suggests escalating pain that needs prompt assessment.
Other choices are incorrect:
D: Peripheral edema 2+ bilateral lower extremities could be expected postpartum due to fluid shifts.
E: Uterine tone soft is normal postpartum as the uterus involutes.
F: Large amount of lochia rubra is expected in the early postpartum period.
G: Blood pressure of 136/86 mm Hg is within normal limits postpartum.
Extract:
Question 3 of 5
A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Administer the injection into the vastus lateralis muscle. For newborns, the vastus lateralis muscle is the recommended site for intramuscular injections due to its larger muscle mass and reduced risk of hitting nerves or blood vessels. This site also allows for better absorption of the vaccine. Massaging the site vigorously (
B) can cause tissue damage. Inserting the needle at a 45° angle (
C) is not recommended as it may lead to improper vaccine delivery. Using a 21-gauge needle (
D) is not necessary for newborns and may cause unnecessary pain.
Question 4 of 5
A nurse is assessing a client who is 1 hr postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct action for the nurse to take first in this situation is to massage the client's fundus. This is because excessive vaginal bleeding postpartum can be a sign of uterine atony, which is the most common cause of postpartum hemorrhage. Massaging the fundus helps to stimulate uterine contractions and can help control bleeding. Administering oxytocin (choice
B) can also help with uterine contractions, but massaging the fundus should be done first to assess the situation. Emptying the client's bladder (choice
C) can help relieve pressure on the uterus, but it is not the priority in this situation. Providing oxygen (choice
D) is not indicated for excessive vaginal bleeding unless the client is showing signs of hypoxia.
Question 5 of 5
A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Provide the client with photos of the fetus. This action allows the client to have tangible memories and closure. It can aid in the grieving process and provide a sense of acknowledgment and validation of the loss. Limiting the time the fetus is in the room (
A) may not address the emotional needs of the client. Instructing the client about an autopsy (
C) may be insensitive and overwhelming immediately after the loss. Informing the client about naming requirements (
D) is not a priority at this time and can add unnecessary stress.