ATI RN
ATI RN Maternal Newborn 2023 IV Questions
Extract:
A nurse is assessing a postpartum client who delivered vaginally 8 hr ago. Nurses' Notes: 0700: Breasts soft, nipples intact. Uterus firm, midline, at umbilicus. Moderate lochia rubra. Episiotomy well approximated, mild edema, ecchymosis. Pain 2/10. Able to void, no bladder distention. DTR 1+. Peripheral edema 2+ in legs. 1100: Breasts soft, nipples intact. Uterus soft, laterally deviated, 1 cm above umbilicus. Large lochia rubra. Pain 3/10. DTR 1+. Peripheral edema 2+ in legs. Vital Signs: 0700: Temp 36.2°C, Pulse 80/min, RR 16/min, BP 136/82 mmHg, SpO2 99%. 1100: Temp 37.2°C, Pulse 85/min, RR 18/min, BP 136/86 mmHg, SpO2 100%.
Question 1 of 5
Select the 3 findings that require immediate follow-up.
Correct Answer: A, D, G
Rationale: A soft uterus (
A) risks postpartum hemorrhage. Large lochia rubra (
D) may indicate bleeding issues. Lateral uterine deviation (G) suggests a full bladder or complication. BP, edema, pain, and soft breasts are within normal limits.
Extract:
A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage.
Question 2 of 5
Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Administering a lactated Ringer's bolus restores fluid volume and stabilizes blood pressure due to persistent bleeding, addressing the immediate concern of fluid loss.
Extract:
A nurse is assessing a client who is at 28 weeks of gestation and has a Clostridium difficile infection.
Question 3 of 5
The nurse should initiate which of the following types of isolation precautions for the client?
Correct Answer: D
Rationale: C. difficile is transmitted via contact with contaminated surfaces or fecal-oral route, requiring contact precautions (gloves, gown, hand hygiene) to prevent spread.
Extract:
A nurse is reviewing the history of a client who is pregnant.
Question 4 of 5
Which of the following clinical data indicates the client is at risk for preterm delivery?
Correct Answer: A
Rationale: A history of cervical cerclage indicates cervical insufficiency, a known risk factor for preterm delivery. The other findings do not directly correlate with preterm risk.
Extract:
A nurse is assessing a client who is 1 hr postpartum.
Question 5 of 5
Which of the following findings should the nurse report to the provider?
Correct Answer: C
Rationale: A boggy fundus indicates uterine atony, a risk for hemorrhage, requiring immediate reporting. Other findings are normal at 1 hr postpartum.