ATI RN
ATI RN Maternal Newborn 2023 III Questions
Extract:
A nurse is planning care for a client who is 1 hr postpartum and has preeclampsia without severe features.
Question 1 of 5
What actions should the nurse plan to take?
Correct Answer: A
Rationale: Assessing for edema monitors for worsening preeclampsia, a critical step in managing this condition postpartum.
Extract:
A nurse is providing teaching about the expected effects of magnesium sulfate to a client who is at 28 weeks of gestation and has preeclampsia.
Question 2 of 5
Which of the following responses by the nurse is appropriate?
Correct Answer: C
Rationale: Magnesium sulfate prevents seizures in preeclampsia by its anticonvulsant properties, the primary therapeutic goal.
Extract:
A nurse is assessing a full-term newborn upon admission to the nursery.
Question 3 of 5
What clinical findings should the nurse report to the provider?
Correct Answer: B
Rationale: Single palmar creases may indicate genetic conditions like Down syndrome, requiring reporting, unlike normal findings like transient cyanosis.
Extract:
A nurse is caring for a 32-year-old female client who is at 28 weeks of gestation,
Nurses Notes
• The client is a gravida 4, para 3. The client was admitted to the labor and delivery unit with a history of vaginal bleeding for 2 hours. The client states, “I started bleeding a couple of hours ago, but now I am saturating pads with bright red blood. I am so scared something is going to happen to my baby.” The abdomen is soft and nontender to palpation. The client reports no abdominal pain. The perineal pad is saturated with bright red vaginal bleeding, and blood is trickling down the client’s legs. Fundal height is at 27 cm. An electronic fetal monitor placed on the client shows FHR with minimal variability and no decelerations. No uterine contractions or uterine irritability noted. Blood was drawn for type and cross-match.
• 0600: Client admitted with a history of vaginal bleeding for 2 hours. Client reports saturating pads with bright red blood. Abdomen soft and nontender. No abdominal pain reported. Perineal pad saturated with bright red blood, blood trickling down legs. Fundal height at 27 cm. FHR with minimal variability, no decelerations. No uterine contractions or irritability noted. Blood drawn for type and cross-match.
Diagnostic Results
• Blood type and cross-match pending.
• Complete blood count (CBC): Hemoglobin 10.5 g/dL, Hematocrit 32%, Platelets 150,000/mm³.
Medical History
• Gravida 4, para 3.
• Previous pregnancies: 1 full-term vaginal delivery, 1 preterm delivery at 34 weeks, 1 miscarriage at 10 weeks.
• No known allergies.
• No history of hypertension or diabetes.
Vital Signs
• Temperature: 37°C (98.6°F)
• Heart rate: 88/min
• Respiratory rate: 18/min
• Blood pressure: 120/80 mmHg
• Oxygen saturation: 98% on room air
Physical Examination Results
• Abdomen: Soft, nontender, fundal height at 27 cm.
• Perineal area: Saturated pad with bright red blood, blood trickling down legs.
• Fetal heart rate: Minimal variability, no decelerations.
• No uterine contractions or irritability noted.
Provider’s Prescriptions
• Bed rest with bathroom privileges.
• Continuous electronic fetal monitoring.
• Administer Rho(D) immune globulin if the client is Rh-negative.
• IV access with normal saline at 125 mL/hr.
• Prepare for possible ultrasound to assess placental location and fetal well-being.
Question 4 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
Correct Answer:
Rationale: Hematocrit 27%, vaginal bleeding, and FHR 174/min require immediate follow-up due to potential anemia, ongoing hemorrhage, and fetal distress in placenta previa.
Extract:
A nurse is caring for 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: An urge to have a bowel movement during contractions may signal the baby's head descending into the birth canal, indicating rapid labor progression requiring reassessment.