ATI RN
ATI RN Maternal Newborn 2023 Questions
Extract:
A nurse is preparing to perform Leopold maneuvers on a client who is at 36 weeks of gestation.
Question 1 of 5
Identify the sequence of actions the nurse should take.
Order the Items
Source Container
Correct Answer: C, A, B, D, E
Rationale: The correct order is C, A, B, D, E. First, instructing the client to empty their bladder helps provide a clearer view of the uterus and fetal position. Next, positioning the client supine with knees flexed and a small rolled towel under one hip promotes optimal visualization and comfort. Palpating the fetal part in the fundus allows for identification of the presenting part.
Then, palpating the fetal parts along both sides of the uterus helps determine the position and presentation accurately. Finally, palpating the fetal part positioned above the symphysis pubis confirms the engagement and descent of the baby.
Choices F and G are not applicable in this context.
Extract:
A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis. Vital Signs: Blood Pressure 130/72 mm Hg, Heart rate 90/min, Respiratory rate 18/min, Temperature 37°C (98.6°F).
Question 2 of 5
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings? (Select one representative finding)
Correct Answer: B
Rationale: The correct answer is B: Redness in the extremity. This finding could indicate a possible infection, specifically cellulitis, which is a common complication post-operatively. Redness is a sign of inflammation and can be associated with warmth, tenderness, and swelling. It is important for the nurse to recognize this early to prevent further complications. Leukocytosis (
A) may be a nonspecific finding and can be present for various reasons. Scant lochia rubra (
C) is a normal finding in the postpartum period. Increased warmth in the extremity (
D) can be concerning for infection or deep vein thrombosis. Tachycardia (E) can be a sign of various conditions, not specifically related to post-operative complications. Decreased extremity edema (F) is a positive finding indicating improved circulation.
Extract:
A nurse is caring for a client who is at 33 weeks of gestation. Medical History: Gravida 2 Para 1 Preeclampsia.
Question 3 of 5
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings? (Select one representative finding)
Correct Answer: C
Rationale: The correct answer is C: Positive clonus. Clonus is a rhythmic, involuntary muscle contraction and relaxation seen in neurological conditions. A positive clonus indicates abnormal reflex activity, which could signify a neurological issue, potentially related to the client's condition. Platelet count (
A), Hematuria (
B), Proteinuria 2+ (
D), Leukorrhea (E), and BUN 40 mg/dL (F) are not typically related to neurological assessments and do not provide information on neurological status.
Extract:
Nurses Notes 0700: Breasts soft nipples intact. Uterus palpated firm, midline, and at level of 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. 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 4 of 5
Select the 3 findings that require immediate follow-up.
Correct Answer: C, F,G
Rationale: The correct answer is C, F, and G.
C: Lateral deviation of the uterus indicates a possible uterine abnormality that needs immediate follow-up to prevent complications.
F: Soft breasts could be a sign of inadequate lactation or mastitis, requiring prompt intervention.
G: Large amount of lochia rubra suggests excessive postpartum bleeding, which is concerning and necessitates immediate attention.
Other choices are less urgent:
A: Peripheral edema and blood pressure within normal range are common postpartum findings.
D: Pain rating of 3 is mild and does not necessitate immediate follow-up.
E: Uterine tone being soft can be normal in the early postpartum period.
Extract:
A nurse is caring for a client who is experiencing a postpartum hemorrhage and has a new prescription for misoprostol. Medication Administration Record: Misoprostol 800 mcg rectally x 1 dose now, Nifedipine 20 mg PO twice daily, Ketorolac 30 mg IV every 6 hr.
Question 5 of 5
The nurse is assessing the client 30 min later. How should the nurse interpret the findings? (Select one representative finding)
Correct Answer: D
Rationale: The correct answer is D: Fundus firm to palpation. This indicates that the uterus is contracting well, which is important for preventing postpartum hemorrhage. A firm fundus at this time indicates good involution of the uterus.
Choices A, B, and C are indicative of potential issues that would require further assessment and intervention.
Choice A suggests hypotension, B may indicate a urinary tract infection, and C suggests excessive bleeding.
Choice E indicates a higher-than-expected fundal height, which could indicate uterine atony.