ATI RN
RN ATI Maternal Proctored Exam 2023-2024 with NGN Questions
Extract:
A nurse is assessing a postpartum client who delivered vaginally 8 hr ago.
Exhibit 1 - Nurses' Notes: 0700
Breasts soft, nipples intact. Uterus palpated firm, midline, and at the level of the 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.
Exhibit 2 - Nurses' Notes: 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 1 of 5
Select the 3 findings that require immediate follow-up.
Correct Answer: A,B,C
Rationale: The correct findings that require immediate follow-up are A, B, and C.
A: Lateral deviation of the uterus indicates a potential complication like uterine atony or retained placental fragments.
B: Deep tendon reflexes of 1+ could indicate hyporeflexia, which may be a sign of neurological issues.
C: Pain rating of 3 on a scale of 0 to 10 (increased) suggests escalating pain that needs prompt assessment.
Other choices are incorrect:
D: Peripheral edema 2+ bilateral lower extremities could be expected postpartum due to fluid shifts.
E: Uterine tone soft is normal postpartum as the uterus involutes.
F: Large amount of lochia rubra is expected in the early postpartum period.
G: Blood pressure of 136/86 mm Hg is within normal limits postpartum.
Extract:
Question 2 of 5
A nurse is planning care for a client who is 1 hr postpartum and has peripartum cardiomyopathy. Which of the following actions should the nurse plan to take?
Correct Answer: B
Rationale: The correct answer is B: Assess blood pressure twice daily. Postpartum cardiomyopathy is a condition that can lead to heart failure, and monitoring blood pressure is essential to assess cardiac function and detect any signs of worsening heart failure. By assessing blood pressure twice daily, the nurse can identify any fluctuations or abnormalities early on and intervene promptly.
Choice A: Obtaining a prescription for misoprostol is not relevant to the care of a client with peripartum cardiomyopathy.
Choice C: Restricting daily oral fluid intake is not appropriate and may worsen the client's condition by potentially leading to dehydration.
Choice D: Administering an IV bolus of lactated Ringer's is not indicated for peripartum cardiomyopathy unless there is a specific indication such as hypovolemia.
In summary, assessing blood pressure twice daily is crucial for monitoring the client's cardiac status, while the other options are not relevant or may potentially be harmful in this context.
Question 3 of 5
A nurse is assessing a client who is at 6 weeks of gestation and adheres to a vegan diet. Which of the following questions should the nurse ask to assess the client’s dietary intake?
Correct Answer: A
Rationale: The correct answer is A: How much protein do you eat in a day? At 6 weeks of gestation, protein intake is crucial for fetal development. Vegan diets may lack sufficient protein, so assessing this is important.
Choice B is incorrect as Vitamin C is not typically a concern in vegan diets.
Choice C is incorrect as shellfish is not suitable for a vegan diet.
Choice D is incorrect as the client's choice to avoid meat is already known.
Question 4 of 5
A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Assist the client in pulling their knees toward their abdomen. This maneuver helps to widen the pelvic outlet, reducing the angle between the sacrum and the pubic symphysis, thus allowing for easier delivery of the baby's shoulder. By bringing the knees closer to the abdomen, the nurse can help facilitate the rotation of the baby's shoulder, aiding in the resolution of shoulder dystocia.
Applying pressure to the client's fundus (
Choice
A) would not directly address the shoulder dystocia. Pressing firmly on the client’s suprapubic area (
Choice
B) may not be effective in resolving shoulder dystocia. Moving the client onto their hands and knees (
Choice
C) could potentially worsen the situation by further obstructing the baby's passage.
In summary, the McRoberts maneuver, which involves assisting the client in pulling their knees toward their abdomen, is the most appropriate action in managing shoulder dystocia during the second stage of
Question 5 of 5
A nurse is collecting data from a client who is at 30 weeks of gestation. Which of the following findings should the nurse identify as a manifestation of pyelonephritis?
Correct Answer: B
Rationale: The correct answer is B: Flank pain. Pyelonephritis is a kidney infection that commonly presents with symptoms such as flank pain, fever, and urinary symptoms. Flank pain is a key manifestation due to the inflammation of the kidney tissue. Epigastric discomfort (choice
A) is not typically associated with pyelonephritis. While a low-grade fever (choice
C) may be present, a temperature of 37.7°C is not significantly elevated to specifically indicate pyelonephritis. Abdominal cramping (choice
D) is more commonly associated with gastrointestinal issues rather than pyelonephritis.