ATI RN
ATI Maternal Newborn Proctored Exam Latest Update Questions
Extract:
Question 1 of 5
During the first twelve hours following a normal vaginal delivery, the client voids 2,000 mL of urine. How should the nurse interpret this finding?
Correct Answer: D
Rationale: The correct interpretation is D: Normal diuresis after delivery. After childbirth, the body eliminates excess fluid accumulated during pregnancy, leading to increased urine output. This process, known as diuresis, helps to reduce swelling and prevent fluid retention. Voiding 2,000 mL of urine in the first 12 hours is within the expected range for postpartum diuresis.
A: Urinary tract infection - There are no symptoms or signs indicating a urinary tract infection.
B: High output renal failure - This condition is characterized by decreased urine output, not increased.
C: Excessive use of IV fluids during delivery - Excessive IV fluids would not lead to such significant diuresis immediately post-delivery.
In summary, the significant urine output post-vaginal delivery is indicative of normal postpartum diuresis, not any pathological condition.
Question 2 of 5
A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor?
Correct Answer: B
Rationale:
Correct Answer: B - Have you noticed any bloody show or fluid coming from your vagina?
Rationale: Bloody show or fluid leakage can indicate rupture of membranes, a sign of true labor. This suggests the onset of cervical changes and progression towards delivery. It distinguishes true labor from false labor, which typically does not involve such physical signs.
Summary of other choices:
A: "When did your contractions begin?" - This question may provide a timeline for contractions but does not specifically differentiate between true and false labor.
C: "What happens to your contractions when you move about?" - Contractions can vary in intensity based on movement, but this does not definitively differentiate between true and false labor.
D: "Have you felt fetal movement over the last 24 hours?" - Fetal movement is important for assessing fetal well-being but does not directly help in distinguishing true labor from false labor.
Question 3 of 5
A nurse is reinforcing teaching with the parent of a child with a urinary tract infection.
Correct Answer: A
Rationale:
Correct Answer: A
Rationale:
1. Bringing the child to the bathroom before extended trips helps prevent urinary stasis, reducing the risk of urinary tract infection.
2. Emptying the bladder frequently helps flush out bacteria and prevents their growth.
3. This practice promotes good bladder habits and hygiene for the child.
Summary of Incorrect
Choices:
- B: Switching to nylon underwear can increase moisture retention, creating a favorable environment for bacterial growth.
- C: Wiping from back to front can introduce bacteria from the anal area to the urethra, increasing infection risk.
- D: Bubble baths can irritate the urethra and genital area, potentially worsening the infection or causing irritation.
Question 4 of 5
A nurse is caring for a 4-year-old client with full-thickness burns. Which of the following nursing actions are essential for the care of this child? (Select all that apply.)
Correct Answer: A,B,C
Rationale: Level of consciousness, IV fluids, vital signs, and urinary output are critical in burn management; a high-protein, high-calorie diet is recommended instead of a low-calorie diet.
Question 5 of 5
During the first twelve hours following a normal vaginal delivery, the client voids 2,000 mL of urine. How should the nurse interpret this finding?
Correct Answer: D
Rationale: The correct interpretation is D: Normal diuresis after delivery. After childbirth, the body eliminates excess fluid accumulated during pregnancy, leading to increased urine output. This process, known as diuresis, helps to reduce swelling and prevent fluid retention. Voiding 2,000 mL of urine in the first 12 hours is within the expected range for postpartum diuresis.
A: Urinary tract infection - There are no symptoms or signs indicating a urinary tract infection.
B: High output renal failure - This condition is characterized by decreased urine output, not increased.
C: Excessive use of IV fluids during delivery - Excessive IV fluids would not lead to such significant diuresis immediately post-delivery.
In summary, the significant urine output post-vaginal delivery is indicative of normal postpartum diuresis, not any pathological condition.