ATI LPN
ATI PN Maternal Newborn 2023 II Questions
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 1 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:
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 2 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.
Action to Take
Potential Condition
Parameter to Monitor
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 (0900): Temperature: 37° C (98.6° F), Heart rate: 90/min, Blood pressure: 158/100 mm Hg, Respiratory rate: 16/min. (1000): Oxygen saturation: 98% on room air, Heart rate: 95/min, Temperature: 37° C (98.6° F), Blood pressure: 162/110 mm Hg, Respiratory rate: 20/min. Diagnostic Results: Hct: 35% (33 to 47%), Hgb: 10 g/dL (11 to 16 g/dL), Urine: 2+ protein, Platelet count: 95,000/mm³ (150,000 to 400,000/mm³), Aspartate aminotransferase (AST): 200 units/L (0 to 35 units/L), Alanine aminotransferase (ALT): 25 units/L (4 to 36 units/L), Total bilirubin: 1.8 mg/dL (0.3 to 1 mg/dL). Medical History: The client is a 26-year-old primigravida at 28 weeks of gestation. She is obese and has no history of hypertension or diabetes mellitus. She presents with elevated blood pressure, peripheral edema, and headaches. Physical Examination Results: The client is alert and oriented to person, place, and time. Her heart rate is regular, and respirations are even and non-labored. She has 3+ deep tendon reflexes and +2 pitting edema of the bilateral lower extremities. The fetal heart rate (FHR) is 140/min with moderate variability.
Question 3 of 5
Complete the following sentence by using the lists of options. The nurse should first address the client's ___ followed by the client's ___ and ___
Correct Answer: B
Rationale: The nurse should first address the client's blood pressure followed by the client's headache and liver enzymes. High blood pressure indicates preeclampsia, requiring immediate intervention. Headache and elevated liver enzymes (AST 200 units/L) suggest severe preeclampsia complications.
Extract:
Vital Signs: Heart rate: 132/min, Axillary temperature: 36° C (96.8° F), Respiratory rate: 72/min, Weight: 4,366 g (9 lb 10 oz). History and Physical: The newborn was delivered via spontaneous vaginal birth at 41 weeks of gestation. The mother is gravida 2 para 2 with a history of syphilis in the first trimester, treated with penicillin, and no reoccurrence during the pregnancy. The mother also reports intermittent cannabis use during pregnancy. Diagnostic Results: Blood type: A+, Venereal Disease Research Laboratory (VDRL): negative, Rapid Plasma Reagin (RPR): negative, Urine drug screen: Positive for marijuana, negative for opiates, cocaine, amphetamines, or barbiturates. Nurses' Notes: The newborn is lying in a bassinet, lightly swaddled. The newborn is noted to be jittery with a weak cry when disturbed. Extremities are mottled with acrocyanosis. Respirations are rapid and unlabored.
Question 4 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.
Action to Take
Potential Condition
Parameter to Monitor
Correct Answer:
Rationale: Hypoglycemia is most likely given the newborn's jitteriness, weak cry, and mottled extremities. Actions: Feed the newborn to increase blood sugar; monitor phototherapy for jaundice. Parameters: Assess skin integrity; monitor bilirubin levels.
Extract:
Vital Signs: Temperature: 36.6°C (98°F), Heart rate: 112/min, Respiratory rate: 20/min, Blood pressure: 92/52 mm Hg. Diagnostic Results: Hct: 50% (Normal: 37% to 47%), Blood glucose: 110 mg/dL (Normal: 74 to 106 mg/dL), Hgb: 18 g/dL (Normal: 12 to 16 g/dL), Urinalysis: Potassium: 3.2 mEq/L (Normal: 3.5 to 5 mEq/L), Ketones: positive (Normal: none), Protein: negative (Normal: none). Nurses' Notes: Client presents with reports of nausea and vomiting for the past several weeks, which has worsened in severity. Client states that they have been unable to retain even clear fluids for the past 48 hours. Client denies pain. Client reports a history of migraines and asthma.
Question 5 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.
Action to Take
Potential Condition
Parameter to Monitor
Correct Answer: C
Rationale: Hyperemesis gravidarum is characterized by severe nausea and vomiting. Actions: Inspect mucous membranes for dehydration; administer antiemetics. Parameters: Monitor electrolyte values and urine ketones.