ATI LPN
ATI PN Maternal Newborn 2023 II Questions
Extract:
Nurses' Notes: At 0625, the client is alert and oriented, at 38 weeks of gestation, presenting to the labor and delivery unit for evaluation of fluid leaking from the vagina. The client states they felt a small gush of fluid and thinks their membranes have ruptured. At 0830, mild contractions are occurring 20 minutes apart, irregular, lasting 40 seconds. The client rates the pain as a 3 on a scale of 0 to 10. An electronic fetal monitor is applied. The client voided 50 mL of clear yellow urine in a bedpan. Mild contractions are now 15 minutes apart, irregular, lasting 30 seconds. The cervix is 2 cm dilated with 20% effacement. The client rates pain as a 4 on a scale of 0 to 10. The fetal heart rate (FHR) is 132/min with moderate variability.
Question 1 of 5
The nurse is assisting with planning care for the client. After review of the client's electronic medical record (EMR), which of the following interventions should the nurse recommend as anticipated, nonessential, or contraindicated?
| Options | Indicated | Non-Essential | Contraindicated |
|---|---|---|---|
| Encourage frequent ambulation | |||
| Ensure the client maintains a supine position while in bed | |||
| Check FHR every 30 min | |||
| Perform a Nitrazine test | |||
| Prepare the client for catheterization | |||
| Obtain CBC blood sample | |||
| Check the client's temperature every hour |
Correct Answer: A: Anticipated, B: Contraindicated, C: Anticipated, D: Anticipated, E: Nonessential, F: Nonessential, G: Anticipated
Rationale: A: Encourages labor progression. B: Can impede labor and fetal oxygenation. C: Ensures fetal well-being. D: Confirms rupture of membranes. E: Not needed with spontaneous voiding. F: No signs of infection. G: Monitors for infection post-rupture.
Extract:
A nurse is reinforcing teaching about outpatient resources for a client who is recovering from a molar pregnancy.
Question 2 of 5
Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: B
Rationale: Attending a support group is crucial for emotional support and ensuring that the client has access to resources and information about recovery and future pregnancy planning.
Extract:
Vital Signs: Heart rate: 84/min, Temperature: 37.3°C (99.1°F), Blood pressure: 128/82 mm Hg, Respiratory rate: 18/min. Diagnostic Results: Blood glucose: 120 mg/dL (Normal: 74 to 106 mg/dL). Medical History: The client is a 24-year-old female with a history of type 1 diabetes mellitus first diagnosed at 14 years of age. The client is on insulin for diabetes management. No other significant prenatal history is noted. The client is gravida 1 para 1 following a spontaneous vaginal birth at 37 weeks of gestation. The newborn was large for gestational age, weighing 4.1 kg (9 lb). The client has a third-degree laceration that required several stitches. Nurses' Notes: Client was admitted to the postpartum unit 4 hours after delivery. The fundus is firm and midline at the level of the umbilicus. Lochia is moderate. A lunch tray was given. The newborn is sleeping in a bassinet next to the client's bed. The client is diaphoretic, with skin that is clammy. Pulse is rapid, strong, and regular, and respirations are shallow. The client reports a headache, slight nausea, and feeling weak.
Question 3 of 5
Complete the following sentence by using the list of options. The nurse should plan to ___ then ___
Correct Answer: A
Rationale: The nurse should plan to check the client's blood glucose level then implement seizure precautions. Symptoms suggest hypoglycemia, common in diabetic patients, requiring glucose check and seizure precautions.
Extract:
A nurse is reinforcing teaching about perineal care to a client who is 2 hours postpartum and has an episiotomy and hemorrhoids.
Question 4 of 5
Which of the following statements by the client indicates understanding of the teaching?
Correct Answer: D
Rationale: Applying witch hazel pads after urination helps reduce swelling, provides soothing relief, and promotes healing for both hemorrhoids and episiotomy sites. Witch hazel has natural astringent properties that are beneficial for postpartum perineal care.
Extract:
A nurse is reinforcing teaching about risk factors for preeclampsia with a group of clients who are pregnant.
Question 5 of 5
Which of the following risk factors should the nurse include in the teaching?
Correct Answer: D
Rationale: Chronic hypertension is a well-known risk factor for preeclampsia as it indicates pre-existing cardiovascular issues that can predispose one to developing preeclampsia during pregnancy.