ATI RN
ATI RN Maternal Newborn Updated 2023 Questions
Extract:
A client who is taking an oral contraceptive.
Question 1 of 5
The nurse should instruct the client to report which of the following findings to the provider immediately?
Correct Answer: B
Rationale: The correct answer is B: Persistent headaches. Headaches can indicate serious conditions like hypertension or preeclampsia, requiring immediate medical attention to prevent complications. Breast tenderness, vaginal itching, and painful intercourse are common discomforts during pregnancy but typically not urgent issues. Reporting persistent headaches promptly can ensure timely intervention and prevent potential risks to the client and fetus.
Extract:
A client who delivered by cesarean birth 6 hr ago.
Question 2 of 5
The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Administer 500 mL lactated Ringer's IV bolus. This action is necessary to address potential hypovolemia due to the steady vaginal bleeding. Lactated Ringer's solution helps restore intravascular volume and maintain perfusion. Evaluating urinary output (
A) is important but not the priority when immediate action is needed. Replacing the surgical dressing (
B) is not the first step in managing ongoing bleeding. Applying an ice pack to the incision site (
C) is not indicated and may not address the underlying issue.
Extract:
A client who is in labor and has a spontaneous rupture of membranes. The nurse notes that the umbilical cord is protruding from the client's vagina.
Question 3 of 5
After calling for help, which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct action is A: Use fingers to exert upward pressure on the presenting part. This is the first step in managing a prolapsed cord to alleviate pressure on the cord and prevent fetal hypoxia. Immediate action is crucial in this emergency situation. Administering tocolytic medication (
B) is not the priority as it does not address the immediate risk to the fetus. Applying oxygen via facemask (
C) is important but secondary to relieving cord compression. Wrapping the cord in a sterile towel (
D) is not recommended as it can further compress the cord.
Extract:
A client who is at 28 weeks of gestation and received no immunizations during childhood.
Question 4 of 5
Which of the following vaccines should the nurse plan to administer?
Correct Answer: C
Rationale: The correct answer is C: Tetanus. Tetanus vaccine should be administered routinely to prevent tetanus, a serious bacterial infection. The other choices are incorrect because: A: Human papillomavirus vaccine is typically given to prevent HPV-related cancers; B: Rubella vaccine is given to prevent rubella, a viral infection that can cause birth defects; D: Varicella vaccine is given to prevent chickenpox, a viral infection. In this case, the nurse should plan to administer the tetanus vaccine for routine preventive care.
Extract:
A client who is in labor.
Question 5 of 5
Which of the following findings should prompt the nurse to reassess the client?
Correct Answer: B
Rationale: The correct answer is B. An urge to have a bowel movement during contractions should prompt the nurse to reassess the client because it could indicate the need to push, which could lead to premature delivery. This finding can signal the need for further evaluation to prevent complications. Intense contractions lasting 45 to 60 seconds (
A) are normal during labor. A sense of excitement and warm, flushed skin (
C) can be a normal response to the labor process. Progressive sacral discomfort during contractions (
D) is common due to pressure on the sacrum during labor.