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 5
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 reviewing the medical record of a client who had a vaginal delivery 3 hr ago."
Question 2 of 5
Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply.)
Correct Answer: A, C, D
Rationale: The correct answers are A, C, and D. Vacuum-assisted delivery can lead to uterine atony, increasing the risk of postpartum hemorrhage. History of uterine atony is a risk factor itself. Labor induction with oxytocin can cause rapid and prolonged contractions, leading to postpartum hemorrhage.
Choices B and E are not directly related to postpartum hemorrhage risk. Human papillomavirus does not increase the risk, and newborn weight is not a factor in postpartum hemorrhage.
Extract:
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid.
Question 3 of 5
Which of the following actions should the nurse include in the plan of care?
Correct Answer: A
Rationale: The correct answer is A: Administer broad-spectrum antibiotics. This is essential in the plan of care to treat a suspected infection. Antibiotics can target a wide range of bacteria, covering potential pathogens until specific cultures can identify the causative organism. Cleansing the site with povidone-iodine (
B) is important for local hygiene but does not address systemic infection. Monitoring rectal temperature (
C) is a good assessment measure but does not actively treat infection. Preparing for surgical closure after 72 hr (
D) may be necessary but does not address the immediate need to manage infection.
Extract:
A nurse is caring for a client who is 1 hr postpartum and has uterine atony. The client is exhibiting a large amount of vaginal bleeding.
Question 4 of 5
Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Anticipate a prescription for misoprostol. This is the correct action because misoprostol is commonly used in obstetrics to induce labor or manage postpartum hemorrhage. The nurse should anticipate this prescription to be prepared to administer it as needed.
Choice A is incorrect as sterile vaginal examinations may be necessary for assessment and care.
Choice C is incorrect as a Kleihauer-Betke test is used to detect fetal-maternal hemorrhage, not typically indicated in this scenario.
Choice D is incorrect as betamethasone is a corticosteroid used for fetal lung maturity, not indicated in this situation.
Extract:
A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver.
Question 5 of 5
Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct action is to assist the client in pulling their knees toward their abdomen (
Choice
A) to facilitate the delivery of the shoulders during a shoulder dystocia. This maneuver helps to create more space in the birth canal for the baby's shoulder to pass through. Applying pressure to the fundus (
Choice
B) could potentially cause harm to the baby. Pressing firmly on the suprapubic area (
Choice
C) is not an appropriate action during shoulder dystocia. Moving the client onto their hands and knees (
Choice
D) could worsen the situation by altering the position of the baby. It is crucial to choose the action that is evidence-based and designed to resolve the specific issue at hand effectively.