ATI RN
ATI RN Maternal Newborn 2023 Questions
Extract:
A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis. Vital Signs: Blood Pressure 130/72 mm Hg, Heart rate 90/min, Respiratory rate 18/min, Temperature 37°C (98.6°F).
Question 1 of 4
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings? (Select one representative finding)
Correct Answer: B
Rationale: The correct answer is B: Redness in the extremity. This finding could indicate a possible infection, specifically cellulitis, which is a common complication post-operatively. Redness is a sign of inflammation and can be associated with warmth, tenderness, and swelling. It is important for the nurse to recognize this early to prevent further complications. Leukocytosis (
A) may be a nonspecific finding and can be present for various reasons. Scant lochia rubra (
C) is a normal finding in the postpartum period. Increased warmth in the extremity (
D) can be concerning for infection or deep vein thrombosis. Tachycardia (E) can be a sign of various conditions, not specifically related to post-operative complications. Decreased extremity edema (F) is a positive finding indicating improved circulation.
Extract:
A nurse is caring for a client who is at 33 weeks of gestation. Medical History: Gravida 2 Para 1 Preeclampsia.
Question 2 of 4
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings? (Select one representative finding)
Correct Answer: C
Rationale: The correct answer is C: Positive clonus. Clonus is a rhythmic, involuntary muscle contraction and relaxation seen in neurological conditions. A positive clonus indicates abnormal reflex activity, which could signify a neurological issue, potentially related to the client's condition. Platelet count (
A), Hematuria (
B), Proteinuria 2+ (
D), Leukorrhea (E), and BUN 40 mg/dL (F) are not typically related to neurological assessments and do not provide information on neurological status.
Extract:
Nurses Notes 0700: Breasts soft nipples intact. Uterus palpated firm, midline, and at level of 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. 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 3 of 4
Select the 3 findings that require immediate follow-up.
Correct Answer: C, F,G
Rationale: The correct answer is C, F, and G.
C: Lateral deviation of the uterus indicates a possible uterine abnormality that needs immediate follow-up to prevent complications.
F: Soft breasts could be a sign of inadequate lactation or mastitis, requiring prompt intervention.
G: Large amount of lochia rubra suggests excessive postpartum bleeding, which is concerning and necessitates immediate attention.
Other choices are less urgent:
A: Peripheral edema and blood pressure within normal range are common postpartum findings.
D: Pain rating of 3 is mild and does not necessitate immediate follow-up.
E: Uterine tone being soft can be normal in the early postpartum period.
Extract:
A nurse is caring for a client who is experiencing a postpartum hemorrhage and has a new prescription for misoprostol. Medication Administration Record: Misoprostol 800 mcg rectally x 1 dose now, Nifedipine 20 mg PO twice daily, Ketorolac 30 mg IV every 6 hr.
Question 4 of 4
The nurse is assessing the client 30 min later. How should the nurse interpret the findings? (Select one representative finding)
Correct Answer: D
Rationale: The correct answer is D: Fundus firm to palpation. This indicates that the uterus is contracting well, which is important for preventing postpartum hemorrhage. A firm fundus at this time indicates good involution of the uterus.
Choices A, B, and C are indicative of potential issues that would require further assessment and intervention.
Choice A suggests hypotension, B may indicate a urinary tract infection, and C suggests excessive bleeding.
Choice E indicates a higher-than-expected fundal height, which could indicate uterine atony.
Extract:
A nurse is caring for a term newborn who is 48 hr old. Physical Examination: High-pitched cry, Mild tremors when disturbed, Increased muscle tone, Sneezing six times within 1 hr, Excessive sucking, Color: Consistent with genetic background, Excoriation of the chin, Watery stools, Projectile vomiting, Hyperactive Moro reflex.
Question 5 of 4
The nurse is assessing the newborn 24 hr later. How should the nurse interpret the findings? (Select one representative finding)
Correct Answer: D
Rationale: The correct answer is D: Continuous high-pitched cry. This finding indicates potential issues like discomfort, hunger, or illness in the newborn. It's concerning because continuous crying can be a sign of distress or underlying medical problems. Regurgitation (
A) is common in newborns due to immature digestive system. Mottling (
B) is a transient skin discoloration that can occur normally in newborns. Transient strabismus (
C) is common as newborns' eye muscles are still developing. Respiratory rate of 70/min (E) is within the normal range for newborns. Loose stools (F) are expected in breastfed newborns.