ATI RN
ATI Comprehensive 2023 With NGN 180 Questions And Answers Questions
Extract:
A nurse is caring for a client in active labor.
Admission Assessment
0200:
Gravida 1, Para 0 at 39 weeks gestation. Presents with contractions occurring every 5 to 6 min,
45 to 60 seconds duration. Cervical examination 4 cm dilated, 50% effaced. Admit to labor and
delivery unit.
Nurses' Notes
0200:
Admitted to labor and delivery unit, reports pain as 7 on a scale of 0 to 10 with contractions.
Cervix 4 cm dilated, 50% effaced, with membranes intact.
0230:
Client reports increasing discomfort with contractions. Cervix 5 cm dilated, 60% effaced, with
membranes intact. Contractions occurring every 5 min, 45 to 60 seconds duration.
0300:
Epidural anesthesia initiated, Cervix 7 cm dilated, 70% effaced, with membranes intact.
Contractions occurring every 4 to 5 min. 60 seconds duration,
Vital Signs
0200:
Temperature 36.9° C (98.4° F)
Heart rate 86/min
Respiratory rate 18/min
BP 118/78 mm Hg
0230:
Temperature 37° C (98.6° F)
Heart rate 88/min
Respiratory rate 20/min
BP 120/80 mm Hg
0300:
Temperature 37.1°C?98.8°F?
Heart rate 90/min
Respiratory rate 18/min
BP 122/76 mm Hg
The nurse is assuming care for the client at 0305.
Question 1 of 5
For each nursing action, click to specify if the nursing action is essential or contraindicated for the client.
| Nursing Action | Essential | Contraindicated |
|---|---|---|
| Assist the client with ambulation | ||
| Inform the client to expect drowsiness | ||
| Monitor for elevated temperature | ||
| Assess for urinary retention | ||
| Encourage the client to turn from side to side |
Correct Answer: C,D,E
Rationale: Monitoring temperature, assessing urinary retention, and encouraging position changes are essential after epidural administration.
Extract:
Question 2 of 5
Correct Answer:
Rationale:
Question 3 of 5
Correct Answer:
Rationale:
Question 4 of 5
Correct Answer:
Rationale:
Question 5 of 5
Correct Answer:
Rationale: