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 choices for immediate follow-up are A, B, and C. A lateral deviation of the uterus could indicate a possible complication like uterine atony or retained products of conception. Deep tendon reflexes of 1+ could suggest hyporeflexia or neurological issues. A pain rating of 3 on a scale of 0 to 10, especially if it has increased, may indicate worsening pain or a new issue.
Choices D, E, F, and G do not present immediate concerns that require urgent follow-up compared to choices A, B, and C. Peripheral edema 2+ in bilateral lower extremities, soft uterine tone, large amount of lochia rubra, and a blood pressure of 136/86 mm Hg are important findings but do not necessitate immediate intervention or follow-up.
Extract:
A nurse is caring for a postpartum client who gave birth 3 days ago.
Exhibit 1
Vital Signs
Temperature 38.4° C (101.1° F)
Heart rate 108/min
Respiratory rate 20/min
Blood pressure 118/72 mm Hg
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:
Rationale:
Correct
Answer: Action to Take: A, B; Potential Condition: B; Parameter to Monitor: C, E.
Rationale:
1. Potential Condition: Engorgement is a common condition postpartum characterized by breast fullness and tenderness.
2. Actions to Take: Initiate anticoagulant therapy to prevent deep vein thrombosis and administer an oxytocic medication to relieve engorgement.
3. Parameters to Monitor: Circumference of lower extremities (for DVT) and integrity of the nipples (for engorgement). These parameters will help assess the client's progress in managing these conditions effectively.
Extract:
A nurse in the emergency department is caring for a 19-year-old client
who is at 18 weeks of gestation.
Exhibit 1
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
hr. Client reports no pain. Client reports a history of migraines
and asthma.
Question 3 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:
Correct
Answer: Action to Take: A, B; Potential Condition: B; Parameter to Monitor: C, E.
Rationale: The potential condition the client is most likely experiencing is ectopic pregnancy. The nurse should insert a peripher-all access device to administer medications and fluids, and perform daily fetal movement counts to monitor fetal well-being. The nurse should monitor urine ketones to assess for dehydration and Kleihauer-Betke values to evaluate for internal bleeding, which are common in ectopic pregnancies. Serum human chorionic gonadotropin (hCG) levels should also be monitored to track the progression of the pregnancy and ensure appropriate management.
Extract:
A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hr old.
Physical Examination:
• Fontanels soft and flat
• Head molded with caput succedaneum
• Eyes symmetric, no discharge, sclera yellow
• Mucous membranes dry
• Abdomen soft and rounded, bowel sounds present x 4 quadrants
Question 4 of 5
Which of the following findings should the nurse report to the provider? (Select all that apply.)
Correct Answer: A,B,C,G
Rationale: The correct answers to report to the provider are A, B, C, and G.
A: Coombs test result is crucial for diagnosing hemolytic anemia.
B: Mucous membrane assessment reflects hydration and oxygenation status.
C: Intake and output are vital for monitoring fluid balance.
G: Sclera color can indicate jaundice or liver dysfunction.
Other choices like D, E, and F are important assessments but not as critical for immediate provider notification. The respiratory rate (
D) and heart rate (F) are essential vital signs but can be monitored routinely. Head assessment findings (E) can be important but may not require immediate provider notification unless there is a significant change.
Extract:
A nurse is caring for a client who is at 33 weeks of gestation.
Diagnostic Results:
• Proteinuria 3+, straw-colored urine
• Platelet count 150,000/mm3 (150,000 to 400,000/mm3)
• BUN 18 mg/dL (10 to 20 mg/dL)
Question 5 of 5
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
| Findings 24 hr later | Sign of potential worsening condition | Sign of potential improvement | Unrelated to diagnosis |
|---|---|---|---|
| Hematuria | |||
| Proteinuria 2+ | |||
| Leukorrhea | |||
| Positive clonus | |||
| BUN 40 mg/dL | |||
| Platelet count 110,000/mm3 |
Correct Answer:
Rationale:
Correct
Answer:
Rationale:
- Hematuria and Proteinuria 2+ are relevant findings that may indicate a potential worsening condition.
- Leukorrhea is unrelated to the diagnosis and should not be considered for interpretation.
- Positive clonus is a sign of potential improvement as it suggests a neurological response.
- BUN 40 mg/dL is a critical value that indicates potential renal impairment.
- Platelet count 110,000/mm3 is a concerning finding that suggests a potential worsening condition.