RN ATI Maternal Proctored Exam 2023-2024 with NGN -Nurselytic

Questions 63

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RN ATI Maternal Proctored Exam 2023-2024 with NGN Questions

Extract:


Question 1 of 5

A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?

Correct Answer: B

Rationale: The correct answer is B: Transmission can occur via the saliva and urine of the newborn. Maternal cytomegalovirus can be transmitted to the newborn through contact with infected bodily fluids such as saliva and urine. This is important for the nurses to understand as they care for both the mother and the newborn to prevent transmission.


Choice A is incorrect because acyclovir is not used to treat cytomegalovirus, but rather for other viral infections like herpes.
Choice C is incorrect because lesions are not typically visible on the mother's genitalia with cytomegalovirus.
Choice D is incorrect because airborne precautions are not necessary for cytomegalovirus transmission.

Question 2 of 5

A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?

Correct Answer: C

Rationale: The correct answer is C: Initiate seizure precautions. Neonatal abstinence syndrome can lead to seizures due to drug withdrawal. Seizure precautions involve ensuring a safe environment, padded crib, monitoring vital signs closely, and having emergency medications and equipment readily available. Monitoring blood glucose every hour (
A) is not typically necessary for neonatal abstinence syndrome. Placing the infant on their back with legs extended (
B) is a basic positioning technique and not specific to addressing the syndrome. Providing a stimulating environment (
D) would be inappropriate and could exacerbate symptoms.

Question 3 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 of their stillborn child, which can aid in the grieving process and provide closure. Providing photos is a sensitive and compassionate gesture that acknowledges the significance of the loss. It also respects the client's autonomy in choosing how they wish to remember their child.
The other choices are not appropriate in this situation:
A: Limiting the time the fetus is in the room may not consider the emotional needs of the client.
C: Instructing the client about an autopsy may be insensitive and distressing without discussing it first with the client.
D: Informing the client about naming the fetus is not a legal requirement and could add unnecessary pressure during a difficult time.

Extract:

A nurse in the emergency department is caring for a 19-year-old client
who is at 18 weeks of gestation.
Exhibit 1
Nurses' Notes
Client presents with reports of nausea and vomiting for the past
several weeks, which has worsened in severity. Client states that
they have been unable to retain even clear fluids for the past 48
hr. Client reports no pain. Client reports a history of migraines
and asthma.


Question 4 of 5

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Action to Take

Insert a peripher-all access device
Perform daily fetal movement counts
Prepare client for surgery

Potential Condition

Ectopic pregnancy
Hyperemesis gravidarum
Gestational diabetes mellitus

Parameter to Monitor

Urine ketones
Kleihauer-Betke values
Serum human chorionic gonadotropin (hCG) levels

Correct Answer:

Rationale:
Correct Answer: Action to Take: A, B; Potential Condition: B; Parameter to Monitor: C, E.


Rationale: The potential condition the client is most likely experiencing is ectopic pregnancy. The nurse should insert a peripher-all access device to administer medications and fluids, and perform daily fetal movement counts to monitor fetal well-being. The nurse should monitor urine ketones to assess for dehydration and Kleihauer-Betke values to evaluate for internal bleeding, which are common in ectopic pregnancies. Serum human chorionic gonadotropin (hCG) levels should also be monitored to track the progression of the pregnancy and ensure appropriate management.

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 possible complication like uterine atony or retained products of conception. Deep tendon reflexes of 1+ could suggest hyporeflexia or neurological issues. A pain rating of 3 on a scale of 0 to 10, especially if it has increased, may indicate worsening pain or a new issue.

Choices D, E, F, and G do not present immediate concerns that require urgent follow-up compared to choices A, B, and C. Peripheral edema 2+ in bilateral lower extremities, soft uterine tone, large amount of lochia rubra, and a blood pressure of 136/86 mm Hg are important findings but do not necessitate immediate intervention or follow-up.

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