ATI RN
ATI RN Maternal Newborn Latest Update. Questions
Extract:
A nurse is assessing a postpartum client during a follow-up visit.
Exhibit 3 - Vital Signs
Time Vital Signs
0930 Temperature 37°C (98.6°F)
Pulse rate 78/min
Respiratory rate 12/min
Blood pressure 124/80 mm Hg
Pulse oximetry 100%
Question 1 of 5
The nurse is teaching the client about postpartum depression. The nurse should encourage the client to----------------- and ----------------- to help prevent postpartum depression.
Correct Answer:
Rationale:
Correct
Answer: C: Get adequate rest and sleep
Rationale:
1. Sleep deprivation is a common trigger for postpartum depression.
2. Adequate rest and sleep help regulate mood and reduce stress levels.
3. Lack of sleep can worsen depressive symptoms.
4. Rest and sleep are essential for physical and emotional recovery postpartum.
Summary:
A: Engaging in physical activity is beneficial but not directly linked to preventing postpartum depression.
B: While a support system is important, it may not solely prevent postpartum depression.
D: Eating a well-balanced diet is crucial for overall health but not the primary focus for preventing postpartum depression.
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 2 of 5
Select the 3 findings that require immediate follow-up.
Correct Answer: A,B,C
Rationale: The correct answers are A, B, and C. A lateral deviation of the uterus could indicate a potential complication such as uterine inversion. Deep tendon reflexes being 1+ may suggest hyporeflexia, which could be a sign of neurological issues. A pain rating of 3 on a scale of 0 to 10, especially if increased, may indicate worsening pain that needs immediate attention.
Choices D, E, F, and G do not require immediate follow-up as they are not indicative of urgent conditions. Peripheral edema 2+ bilateral lower extremities may be normal postpartum. Uterine tone being soft is expected in the postpartum period. A large amount of lochia rubra is typically seen in the immediate postpartum period. Blood pressure of 136/86 mm Hg is within normal limits for a postpartum patient.
Extract:
Question 3 of 5
A nurse is caring for a client who is receiving an epidural block with an opioid analgesic. The nurse should monitor for which of the following findings as an adverse effect of the medication?
Correct Answer: C
Rationale:
Correct
Answer: C - Hypotension
Rationale: Opioid analgesics can cause vasodilation leading to hypotension due to decreased systemic vascular resistance. The nurse should monitor the client for signs of hypotension such as lightheadedness, dizziness, and decreased blood pressure. Monitoring for hypotension is crucial to prevent complications like decreased perfusion to vital organs.
Summary:
A: Hyperglycemia - Opioid analgesics do not typically cause hyperglycemia.
B: Bilateral crackles - This finding is more indicative of fluid overload or heart failure, not a direct effect of opioid analgesics.
D: Polyuria - Opioid analgesics do not usually cause polyuria; in fact, they can cause urinary retention as a side effect due to bladder sphincter relaxation.
Question 4 of 5
A nurse is providing teaching to a client who is at 35 weeks of gestation and has a prescription for an amniocentesis. Which of the following client statements indicates an understanding of the teaching?
Correct Answer: A
Rationale: The correct answer is A. Emptying the bladder before amniocentesis helps prevent injury to the bladder during the procedure. This statement shows understanding of the importance of bladder emptying for safety and accuracy.
B: Incorrect. The client is typically lying on their back during amniocentesis.
C: Incorrect. The client is awake during the procedure.
D: Incorrect. Fasting is not required for amniocentesis.
Question 5 of 5
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Initiate seizure precautions. Neonatal abstinence syndrome can result in neurological symptoms, including seizures. Initiating seizure precautions involves ensuring a safe environment, padding the crib, and closely monitoring the infant for any signs of seizure activity. Monitoring blood glucose every hour (
A) is not typically indicated for neonatal abstinence syndrome. Placing the infant on his back with legs extended (
B) is a standard safe sleep practice but is not specific to managing neonatal abstinence syndrome. Providing a stimulating environment (
D) can exacerbate symptoms of withdrawal and should be avoided.