ATI RN
ATI RN Maternal Newborn 2023 Exam 4 Questions
Extract:
A nurse is caring for a patient who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding.
Question 1 of 5
After calling for assistance and notifying the provider, which of the following actions should the nurse take next?
Correct Answer: C
Rationale: The correct answer is C because performing a vaginal examination by applying upward pressure on the presenting part helps assess the progress of labor and fetal descent, which is crucial in determining the need for immediate intervention or transfer. Initiating an infusion of IV fluids (
A) is not the next step as the priority is to assess the progress of labor first. Administering oxygen (
B) may be important but not the immediate next step after notifying the provider. Performing a vaginal examination (
C) is more critical in this situation. Covering the umbilical cord with a sterile saline towel (
D) is not necessary at this point.
Extract:
A nurse is caring for a client who delivered by cesarean birth 6 hours ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage.
Question 2 of 5
Which action should the nurse take?
Correct Answer: A
Rationale: The correct action is A: Administer 500 mL lactated Ringer's IV bolus. This choice is correct because the patient may be experiencing hypovolemia post-surgery, requiring fluid resuscitation to maintain hemodynamic stability. Evaluating urinary output (
B) is important but may not address the immediate need for fluid resuscitation. Applying an ice pack (
C) may be indicated for pain management but does not address potential hypovolemia. Replacing the surgical dressing (
D) is important for wound care but does not address the patient's fluid volume deficit.
Extract:
A nurse is teaching a client who is experiencing infertility about clomiphene citrate.
Question 3 of 5
Which adverse effects should the nurse include?
Correct Answer: B
Rationale: The correct answer is B, breast tenderness. As a nurse, it is essential to include this adverse effect because it is commonly associated with certain medications like hormonal therapies. Breast tenderness can be a significant concern for patients and may impact their quality of life. Chills (
A) are more commonly associated with infections or fevers rather than medication side effects. Tinnitus (
C) is a condition related to the ear and not typically a side effect of most medications. Urinary frequency (
D) is more commonly seen with conditions like urinary tract infections rather than medication adverse effects.
Extract:
A nurse is assessing a client who is 1 hour postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding.
Question 4 of 5
What should the nurse do first?
Correct Answer: B
Rationale: Massaging the client's fundus is the priority action to address excessive vaginal bleeding by stimulating uterine contractions.
Extract:
A nurse is caring for a patient who is at 32 weeks of gestation and has complete placenta previa.
Question 5 of 5
Which of the following assessment findings requires immediate follow-up?
Correct Answer: A
Rationale: The correct answer is A: Vaginal bleeding. This finding requires immediate follow-up as it could indicate a serious issue such as placental abruption, ectopic pregnancy, or preterm labor. Prompt assessment and intervention are crucial to ensure maternal and fetal well-being.
Choices B, C, and D are within normal ranges and do not require immediate follow-up.
Choice B (fetal heart rate of 174 bpm) is within the normal range for a fetus.
Choice C (fundal height of 33 cm) is appropriate for gestational age.
Choice D (abdomen soft on palpation and without tenderness) indicates normal findings.