ATI RN
ATI RN Maternal Newborn Latest Update. 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 answer is A, B, and C because they indicate potential health concerns that require immediate follow-up. A, lateral deviation of the uterus, could indicate a possible uterine abnormality or displacement. B, deep tendon reflexes 1+, may suggest neurological issues or abnormalities. C, pain rating of 3 on a scale of 0 to 10 (increased), signifies escalating pain levels that need to be addressed promptly.
Choices D, E, F, and G do not require immediate follow-up as they are within normal ranges or not indicative of urgent issues.
Extract:
Question 2 of 5
A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?
Correct Answer: A
Rationale:
Correct Answer: A
Rationale: It is important for the nurse to instruct the client to have her provider refit her for a new diaphragm because postpartum changes in the body, such as weight loss or gain, can affect the fit of the diaphragm. A properly fitting diaphragm is essential for effective contraception.
Summary:
B: Using oil-based vaginal lubricant can weaken the diaphragm and increase the risk of contraceptive failure.
C: Keeping the diaphragm in place for an extended period after intercourse does not provide additional contraceptive benefits.
D: Storing the diaphragm in sterile water is not necessary and can actually damage the diaphragm.
Question 3 of 5
A nurse is caring for a client who is hypotensive following the administration of epidural anesthesia. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Turn the client to a side-lying position. This action helps improve venous return and cardiac output, which can help increase blood pressure in a hypotensive client. Placing the client in a side-lying position can prevent compression of the vena cava by the uterus, which may occur with epidural anesthesia. Options B, C, and D are incorrect. Applying oxygen via nasal cannula, massaging the fundus, and assisting the client to empty their bladder are not the priority actions in addressing hypotension following epidural anesthesia. Oxygen administration may be important, but positioning the client is the priority in this situation.
Extract:
“A nurse on an antepartum unit is caring for a client.
Exhibit1:
Nurses' Notes 0900:Client reports a small amount of bright red blood in their underwear upon
awakening. Client denies contractions or abdominal pain. External fetal monitor applied.
0930:Client passed large amount of bright red blood from vagina.
Denies pain Uterine tone soft and nontender to palpation.
contraction pattern, no contractions noted.
Fetal heart rate pattern: Fetal heart rate baseline 135/min.
Moderate variability. No decelerations noted.
Exhibit2:
Vital Signs 0900: Temperature 36.2°C (97.2° F) Pulse rate 78/min Respiratory rate 20/min Blood pressure
112/64 mm Hg Fetal heart rate 132/min Pulse rate 82/min Blood pressure 116/60 mm Hg Fetal heart
rate 160/min
Exhibit3:
Medical History. G4P3 30 weeks gestation Previous pregnancies delivered via cesarean section
Question 4 of 5
Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify it the intervention is indicated or contraindicated for the client.
| Potential Nursing Action | Indicated | Contraindicated | |
|---|---|---|---|
| Insert a large bore intravenous catheter. | |||
| Assess cervical dilation. | |||
| Weigh perineal pads. | |||
| Administer methotrexate. |
Correct Answer: A, C
Rationale: [,(0,0,1),(0,0,0),(0,0,0)]
Correct Answer: A, C
Rationale:
A: Inserting a large bore intravenous catheter is indicated for administering medications or fluids rapidly in emergency situations.
C: Weighing perineal pads is indicated to monitor postpartum hemorrhage.
Assessing cervical dilation (
B) is not necessary in this scenario. Administering methotrexate (
D) is not a nursing action.
Extract:
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 an infection of the kidneys that can cause flank pain due to inflammation of the renal parenchyma. This pain is typically located on one or both sides of the lower back, just below the rib cage. Epigastric discomfort (
A) is more commonly associated with conditions like gastritis or pancreatitis. A temperature of 37.7°C (99.8°F) (
C) can indicate a mild fever, but it is not specific to pyelonephritis. Abdominal cramping (
D) is more likely to occur in conditions like gastroenteritis.