ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 of 5
A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: A
Rationale: The correct answer is A: "I should increase my protein intake to 60 grams each day." Increasing protein intake during pregnancy is crucial for the development of the baby's tissues and organs. Protein is essential for cell growth and repair. At 10 weeks of gestation, the client's body needs more protein to support the developing fetus. Choosing this statement shows an understanding of the importance of protein in pregnancy nutrition.
Incorrect
Choices:
B: "I should drink 2 liters of water each day." While hydration is important during pregnancy, this statement does not specifically address the client's nutritional needs.
C: "I should increase my overall daily caloric intake by 300 calories." While additional calories are needed during pregnancy, the specific amount varies depending on individual factors. This statement does not provide a personalized recommendation.
D: "I should take 600 micrograms of folic acid each day." Folic acid is essential for preventing neural tube defects, but this statement does not address overall nutrition or
Question 2 of 5
A nurse is caring for a client who is 1 day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Assess the newborn's latch while breastfeeding. The nurse should assess the newborn's latch to ensure proper attachment to the breast, which can alleviate sore nipples. This step is crucial in addressing the root cause of the issue. Waiting 4 hours between feedings (
A) can lead to engorgement and affect milk supply. Limiting breastfeeding time to 5 minutes (
C) may not be sufficient for adequate feeding. Offering supplemental formula (
D) can interfere with establishing breastfeeding and may not address the underlying latch issue.
Question 3 of 5
A nurse is admitting a client to the labor and delivery unit when the client states, 'My water just broke.' Which of the following interventions is the nurse's priority?
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. This is the priority intervention because assessing the fetal heart rate (FHR) is crucial to ensuring the well-being of the fetus after the client's water has broken. Monitoring the FHR can help detect any signs of distress or complications that may arise. Performing Nitrazine testing (
A) and assessing the fluid (
B) can provide additional information, but monitoring the FHR takes precedence due to its direct impact on fetal well-being. Checking cervical dilation (
C) is important but not as urgent as monitoring the FHR in this situation.
Question 4 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.
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 5 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.