ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
A nurse is caring for a client who is experiencing a postpartum hemorrhage and has a new prescription for misoprostol.
Exhibit 2: Medical History
Preeclampsia
Cesarean birth of viable twin male newborns
Question 1 of 5
The nurse is assessing the client 30 min later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
| Findings 30 min later | Unrelated to diagnosis | Indication Of potential improvement | Indication of Potential worsening condition |
|---|---|---|---|
| Fundus at level of umbilicus | |||
| Cloudy urine | |||
| Blood pressure 80/50 mm Hg | |||
| Moderate lochia rubra | |||
| Thready pulse | |||
| Fundus firm to palpation |
Correct Answer:
Rationale:
Correct Answer:
Rationale:
- Fundus at the level of the umbilicus is an indication of potential improvement as it indicates proper involution of the uterus.
- Cloudy urine is unrelated to the diagnosis and may indicate other issues like urinary tract infection.
- Blood pressure of 80/50 mm Hg is an indication of potential worsening condition as it is hypotensive.
- Moderate lochia rubra is also an indication of potential worsening condition as it may indicate excessive bleeding.
- Thready pulse is unrelated to the diagnosis.
- Fundus firm to palpation is an indication of potential improvement as it indicates proper uterine contraction and involution.
Extract:
Question 2 of 5
A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow.
Correct Answer: A,B,CD
Rationale: The correct sequence for performing Leopold maneuvers is A, B, C, and D. Firstly, palpating the fundus (
A) helps identify the fetal part and presentation. Secondly, determining the location of the fetal back (
B) provides information on the fetal lie. Next, palpating for the fetal part at the inlet (
C) helps confirm the presenting part. Lastly, identifying the attitude of the head (
D) provides important information on the fetal position for delivery. This sequence ensures a systematic approach to assessing the fetal presentation and position.
Choices E, F, and G are incorrect as they do not follow the logical order of Leopold maneuvers and may lead to inaccurate assessment.
Question 3 of 5
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)
Correct Answer: A,C
Rationale:
Correct Answer: A, C
Rationale:
A: Flaccid uterus indicates uterine atony, a common postpartum complication causing excessive bleeding. Oxytocin helps contract the uterus, reducing bleeding.
C: Excess vaginal bleeding is a sign of postpartum hemorrhage. Oxytocin helps by stimulating uterine contractions to control bleeding.
B: Cervical laceration doesn't directly relate to oxytocin administration. It requires repair and not oxytocin.
D: Increased afterbirth cramping is a normal response after delivery, not a direct indication for oxytocin.
Question 4 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 to the heart and increases blood pressure in hypotensive clients. It prevents aortocaval compression, which can lead to decreased cardiac output. Turning the client to a side-lying position is a simple and effective intervention to manage hypotension in this situation.
Other choices are incorrect:
B: Applying oxygen is not the priority in this scenario as the client's hypotension is likely due to the epidural anesthesia and not respiratory distress.
C: Massaging the fundus is not indicated as the client is not postpartum or experiencing uterine atony.
D: Assisting the client to empty their bladder may be important but does not directly address the hypotension caused by epidural anesthesia.
Question 5 of 5
A nurse is calculating the estimated date of delivery for a client who reports that the first day of her last menstrual period was August 10. Using Nägele’s Rule, which of the following is the client’s estimated date of delivery?
Correct Answer: B
Rationale: The correct answer is B: May 17. Nägele's Rule adds 7 days to the first day of the last menstrual period (August 10), then subtracts 3 months and adds 1 year. So, August 10 + 7 days = August 17. Subtracting 3 months gives us May 17, which is the estimated date of delivery.
Choice A (May 13) is incorrect because it doesn't account for adding the additional 7 days.
Choice C (May 3) is incorrect because it miscalculates the subtraction of 3 months.
Choice D (May 20) is incorrect as it adds the 7 days but doesn't subtract 3 months.