ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake 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 potential complication like uterine prolapse. Deep tendon reflexes 1+ could suggest a neurological issue or electrolyte imbalance. A pain rating of 3 on a scale of 0 to 10 (increased) requires further assessment to determine the cause and provide appropriate treatment.
Choices D, E, F, and G are not as urgent. Peripheral edema 2+ bilateral lower extremities could be indicative of fluid retention, which may need monitoring but not immediate intervention. Soft uterine tone may be expected postpartum, and a large amount of lochia rubra could be normal after birth. A blood pressure of 136/86 mm Hg is slightly elevated but not critically high, so it may require monitoring but not immediate follow-up.
Extract:
Question 2 of 5
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. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Administer 500 mL lactated Ringer’s IV bolus. This is the correct action because the persistent vaginal bleeding after cesarean birth could indicate hypovolemia, which requires immediate fluid resuscitation to restore blood volume. Fundal massage alone may not be sufficient if the bleeding is ongoing.
Choice A (Replace the surgical dressing) is incorrect because addressing the vaginal bleeding and hypovolemia takes priority over changing the dressing.
Choice B (Evaluate urinary output) is incorrect as it does not address the immediate need to address the potential hypovolemia from the vaginal bleeding.
Choice C (Apply an ice pack to the incision site) is incorrect as it does not address the underlying cause of the persistent vaginal bleeding and hypovolemia.
In summary, administering a fluid bolus is the most appropriate action to address the possible hypovolemia in this situation.
Question 3 of 5
A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effects should the nurse include?
Correct Answer: A
Rationale: The correct answer is A: Breast tenderness. Clomiphene citrate is a medication commonly used to treat infertility by inducing ovulation. Breast tenderness is a common side effect due to the hormonal changes caused by the medication. This occurs because clomiphene citrate can increase estrogen levels, leading to breast discomfort. Tinnitus (
B), urinary frequency (
C), and chills (
D) are not typically associated with clomiphene citrate use. Tinnitus is more commonly linked to ototoxic medications, urinary frequency may be seen with diuretics, and chills are often indicative of an infection or allergic reaction.
Therefore, breast tenderness is the most relevant adverse effect to include in the teaching for a client experiencing infertility and taking clomiphene citrate.
Extract:
A nurse is caring for a newborn.
Exhibit 1
Medical History
1600:
Apgar score 9 at 1 min and 9 at 5 min
Birth weight 4,706 g (10 lb 6 oz)
Gestational age 40 weeks
Difficult vaginal birth with shoulder dystocia. Exhibit 2
Nurses' Notes
1700:
Newborn is active and moves all extremities except for right arm. No spontaneous movement of
the right arm noted. Right arm remains at side during Moro reflex. Exhibit 3
Physical Examination
1830:
Absent Moro reflex noted in right arm.
Right shoulder and arm are internally rotated and adducted. Elbow extended. Forearm pronated
with wrist and fingers flexed. Diagnosis: Brachial plexus injury resulting in Erb-Duchenne (Erb's
palsy) paralysis.
Question 4 of 5
Which of the following actions should the nurse plan to implement? For each potential nursing action, click to specify if the intervention is indicated or contraindicated for the newborn.
| Potential Nursing Action | Indicated | Contraindicated |
|---|---|---|
| Educate the parents to begin range of motion exercises on the affected arm after 1 week. | ||
| Assess for grasp reflex in the affected extremity. | ||
| Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt. | ||
| Instruct parents to limit physical handling for 2 weeks. |
Correct Answer:
Rationale: [
,
(0, 1, 1),
(0, 0, 1),
(0, 1, 0)
]
Correct Answer: (
B) Assess for grasp reflex in the affected extremity.
Rationale: Assessing for grasp reflex is indicated to evaluate neurological function and response in the affected extremity. Range of motion exercises (
A) are contraindicated as they may exacerbate the condition. Immobilizing the arm (
C) can hinder normal movement and development. Limiting physical handling (
D) may impede bonding and care interactions.
Extract:
Question 5 of 5
A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position. Which of the following questions should the nurse ask to evaluate the effectiveness of this intervention?
Correct Answer: D
Rationale: The correct answer is D: "Has your back labor improved?" This question is relevant because the occipitoposterior position can cause intense back pain during labor. By asking if the back pain has improved, the nurse can assess the effectiveness of the hands-and-knees position in helping to alleviate this specific discomfort.
Choice A: "Does that lessen your suprapubic pain?" is incorrect because the hands-and-knees position is not specifically targeted at suprapubic pain.
Choice B: "Are you feeling relief from your pelvic pressure?" is incorrect because the hands-and-knees position is more effective for back pain relief rather than pelvic pressure.
Choice C: "Do your contractions feel further apart?" is incorrect because the position change may not directly affect the frequency of contractions.
In summary, the correct question (
D) focuses on the specific issue of back labor associated with occipitoposterior position, making it the most relevant evaluation of the intervention.