ATI RN
ATI Nur 232 Maternity Final Exam SP24 Questions
Extract:
A nurse in a community clinic is counseling a client who has been diagnosed with a sexually transmitted infection.
Question 1 of 5
What advice should the nurse provide?
Correct Answer: C
Rationale: Returning in 6 months for retesting ensures monitoring and confirmation of treatment efficacy for STIs, as some require follow-up testing.
Extract:
A nurse is caring for a client who is 4 hours postpartum following a vaginal birth. The client has saturated a perineal pad within 10 minutes.
Question 2 of 5
What should be the nurse's first action?
Correct Answer: A
Rationale: Massaging the fundus is the first action to address potential uterine atony, which may cause rapid bleeding, as indicated by the saturated pad.
Extract:
Vital Signs at 0700 hrs: Temperature: 36.6°C (97.9°F), Pulse: 85/min, Respiratory rate: 20/min, Blood pressure: 180/99 mm Hg. Nurses' Notes at 0700 hrs: Client reports, "I have had a headache for 2 days. Tylenol does not relieve it." Client states, "I have blurred vision and dizziness." Client reports swelling of their feet. 2+ pitting edema of the lower extremities noted bilaterally. Deep tendon reflexes 3+, absent clonus. Fetal heart tones (FH) 150/min. Medical History: Gravida 4 Para 3, 33 weeks of gestation, Allergies: Sulfa, Height: 165 cm (66 in), Weight: 82 kg (180 lb), BMI: 30.6.
Question 3 of 5
Select the 4 assessment findings the nurse should report to the provider.
Correct Answer: A, B, D, G
Rationale: Headache unrelieved by Tylenol, blurred vision and dizziness, 2+ pitting edema, and blood pressure of 180/99 mm Hg are concerning signs of preeclampsia, requiring immediate reporting. Swelling of feet is common and less urgent unless accompanied by other symptoms. Deep tendon reflexes 3+ and fetal heart tones 150/min are normal.
Extract:
Medical History: Gravida: 2, Para: 1, Had an uncomplicated spontaneous vaginal birth 3 years ago of a 7 lb 4 oz infant, Client has no outstanding medical, social, or surgical history, Plan is to induce labor using oxytocin. Nurse's Notes at 0700 hrs: Client is resting in bed, appears anxious about the induction process. Reports mild, irregular contractions, stating they began around midnight. Fetal heart rate (FHR) is 140 beats per minute, with moderate variability. Cervix is 2 cm dilated, 50% effaced, and the fetal head is at -2 station. Client's partner is present and providing support. IV line is in place, and oxytocin infusion is started at 2 mU/min. Client is encouraged to ambulate as tolerated. Nurse's Notes at 0900 hrs: Client reports increased intensity and frequency of contractions, now occurring every 3-4 minutes. FHR is 145 beats per minute, with moderate variability and occasional accelerations. Cervix is now 4 cm dilated, 70% effaced, and the fetal head is at -1 station. Client is experiencing back pain and requests pain relief. IV oxytocin infusion is increased to 6 mU/min as per protocol. Client is repositioned to a side-lying position for comfort. Partner continues to provide support and encouragement. Vital Signs at 0700 hrs: Temperature: 37.2°C (99°F), Blood Pressure: 120/80 mmHg, Heart Rate: 82 beats per minute, Respiratory Rate: 18 breaths per minute. Vital Signs at 0900 hrs: Temperature: 37.5°C (99.5°F), Blood Pressure: 122/78 mmHg, Heart Rate: 88 beats per minute, Respiratory Rate: 20 breaths per minute. Diagnostic Results at 0900 hrs: Fetal scalp pH: 7.25, Amniotic fluid: Clear, no meconium present. A nurse is caring for a client who is 42 weeks of gestation.
Question 4 of 5
Based on the updated assessment findings, which of the following actions should the nurse plan to take? Click to specify whether the nurse's planned actions are anticipated, nonessential, or contraindicated.
| Action | anticipated | nonessential | contraindicated |
|---|---|---|---|
| Increase the oxytocin infusion to 13 mU/min | |||
| Place client in a side-lying position | |||
| Initiate bolus of primary IV fluids | |||
| Apply oxygen at 10 L/min via venturi mask | |||
| Perform sterile vaginal exam | |||
| Assign a Bishop score | |||
| Perform an amniotomy |
Correct Answer: A: Anticipated, B: Anticipated, C: Anticipated, D: Nonessential, E: Anticipated, F: Nonessential, G: Nonessential
Rationale: Increasing the oxytocin infusion to 13 mU/min is anticipated as contractions are progressing and cervical dilation is increasing. Placing the client in a side-lying position is anticipated to improve circulation and alleviate back pain. Initiating a bolus of IV fluids is anticipated to prevent dehydration during labor. Applying oxygen is nonessential as there are no signs of respiratory distress. Performing a sterile vaginal exam is anticipated to monitor labor progression. Assigning a Bishop score is nonessential since labor is already progressing. Performing an amniotomy is nonessential as labor is progressing normally without intervention.
Extract:
A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client's right side.
Question 5 of 5
In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?
Correct Answer: D
Rationale: The findings suggest a breech position with the fetal back on the left, placing the fetal chest (and heart tones) in the right lower quadrant.