ATI RN
ATI Maternity Nur230 Questions
Extract:
Newborn baby boy with vital signs at 1 minute: Heart rate- 160 bpm, Respiratory effort - good, crying vigorously, Muscle tone - active movement, well flexed, Reflex irritability - cries with stimulation of soles of feet, Color - body pink, feet and hands cyanotic
Question 1 of 5
What is the correct Apgar score for this newborn?
Correct Answer: D
Rationale: The Apgar score is 9: 2 (heart rate >100), 2 (vigorous crying), 2 (active movement), 2 (reflex irritability), 1 (partial cyanosis).
Extract:
Client who gave birth 2 hr ago with blood pressure 60/50 mm Hg
Question 2 of 5
A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client's blood pressure is 60/50 mm Hg. What is the first action the nurse should take?
Correct Answer: A
Rationale: A boggy uterus may indicate uterine atony, a common cause of postpartum hemorrhage and hypotension, requiring immediate assessment.
Extract:
Client admitted with suspected deep-vein thrombosis (DVT)
Question 3 of 5
A nurse on the postpartum unit is performing a physical assessment of a client who is being admitted with a suspected deep-vein thrombosis (DVT). Which of the following clinical findings should the nurse anticipate the client will exhibit?
Correct Answer: D
Rationale: Calf tenderness on massage is a classic sign of DVT, indicating inflammation and clot presence.
Extract:
Child with suspected acute rheumatic fever
Question 4 of 5
A nurse is obtaining a health history from a child who has suspected acute rheumatic fever. Which of the following questions should the nurse ask?
Correct Answer: A
Rationale: A recent sore throat may indicate a streptococcal infection, a common precursor to acute rheumatic fever.
Extract:
Client at 36 weeks gestation who has just delivered a stillborn baby
Question 5 of 5
A client at 36 weeks gestation has just delivered a stillborn baby. What should the nurse say?
Correct Answer: A
Rationale: Offering to hold the stillborn baby supports the grieving process, allowing acknowledgment of the loss.