ATI LPN
ATI PN Maternal Newborn 2023 II Questions
Extract:
Vital Signs (0610): Oral temperature: 36.6°C (97.9°F), Heart rate: 120/min, Respiratory rate: 22/min, Blood pressure: 86/48 mm Hg, SaO₂: 96% on room air. Nurses' Notes (0630): The client appears anxious and reports dizziness. She has pale skin and cool extremities. Her abdomen is soft and non-tender with no palpable contractions. She reports no vaginal bleeding or discharge. Deep tendon reflexes are 2+. Peripheral edema is 1+ in bilateral lower extremities. The client is also noted to have tachycardia. Diagnostic Results: Hematocrit (Hct): 25% (normal: >33%), Hemoglobin (Hgb): 9 g/dL (normal: >11 g/dL), Maternal blood type: B+, Platelet count: 110,000/mm³ (normal: 150,000 to 400,000/mm³), WBC count: 12,000/mm³ (normal: 5,000 to 10,000/mm³).
Question 1 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.
Correct Answer: A
Rationale: An ectopic pregnancy is most likely due to the combination of symptoms: dizziness, pale skin, cool extremities, low blood pressure (86/48 mm Hg), and high heart rate (120/min). Actions: Administer methotrexate to stop embryo growth; insert a large-bore peripheral IV catheter to manage blood loss. Parameters: Monitor beta hCG levels to confirm diagnosis; monitor platelet count due to bleeding risk.
Extract:
Vital Signs 0700: Temperature: 36.2°C (97.2°F), Heart rate: 80/min, Respiratory rate: 16/min, Blood pressure: 136/82 mm Hg. 1100: Temperature: 37.2°C (99.0°F), Heart rate: 85/min, Respiratory rate: 18/min, Blood pressure: 136/86 mm Hg, Pulse oximetry: 99%. Nurses' Notes 0700: The client's breasts were soft, and nipples were intact. The uterus was palpated as firm, midline, and at the level of the umbilicus. There was a moderate amount of lochia rubra. The episiotomy site was well approximated with mild edema and ecchymosis. The client reported pain as 2 on a scale of 0 to 10. She was able to void spontaneously, with no bladder distention. Deep tendon reflexes were 1+. Peripheral edema was 2+ in bilateral lower extremities. 1100: The client's breasts remained soft, and nipples were intact. The uterus was palpated as soft with lateral deviation and 1 cm above the umbilicus. There was a large amount of lochia rubra. The episiotomy site was well approximated with mild edema and ecchymosis. The client reported pain as 3 on a scale of 0 to 10. Deep tendon reflexes were 1+. Peripheral edema was 2+ in bilateral lower extremities.
Question 2 of 5
Select the 3 findings that require immediate follow-up.
Correct Answer: B,F,G
Rationale: Lateral deviation of the uterus can indicate bladder distension, which can interfere with uterine contraction and increase the risk of postpartum hemorrhage. A soft uterine tone indicates uterine atony, which can lead to postpartum hemorrhage. A large amount of lochia rubra can be a sign of postpartum hemorrhage.
Extract:
A nurse is reinforcing teaching with a client who is at 18 weeks of gestation and requires an increased intake of iron.
Question 3 of 5
Which of the following foods should the nurse recommend as the best source of iron?
Correct Answer: B
Rationale: Chicken breast is an excellent source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods. Consuming chicken breast helps in meeting the increased iron requirements during pregnancy.
Extract:
Vital Signs: Temperature: 38.4°C (101.1°F), Heart rate: 108/min, Respiratory rate: 20/min, Blood pressure: 118/72 mm Hg. History and Physical: The client is gravida 1 para 1, at 41 weeks of gestation. The client gave birth via cesarean following prolonged rupture of membranes and cephalopelvic disproportion. Assessment: The client's breasts are starting to feel firmer and heavier, and she denies nipple discomfort. The client is bottle-feeding. The uterus is boggy and tender to palpation, with the fundus at the umbilicus. The lochia discharge is moderate, dark brown, and foul-smelling. The client reports frequent voiding without difficulty. Bilateral edema is noted in the lower extremities, without pain, warmth, or tenderness.
Question 4 of 5
Complete the diagram by selecting 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.
Correct Answer: A
Rationale: Endometritis is indicated by fever, tender boggy uterus, and foul-smelling lochia. Actions: Administer antibiotics; monitor oxytocic medication. Parameters: Monitor temperature and lochia.
Extract:
A nurse is obtaining a capillary blood sample from a newborn for phenylketonuria testing.
Question 5 of 5
Identify the sequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Correct Answer: E,A,C,D,B
Rationale: 1. Wrap a warm, moist cloth around the heel. 2. Cleanse the heel with an antiseptic. 3. Puncture the heel and collect the blood. 4. Apply pressure with a dry gauze pad. 5. Cover the heel with an adhesive bandage.