ATI RN
ATI Nur 232 Maternity Final Exam SP24 Questions
Extract:
A nurse is caring for a patient who experienced a vaginal birth 3 hours ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus.
Question 1 of 5
Which actions should the nurse take at this time?
Correct Answer: B
Rationale: Having the patient urinate addresses a potentially full bladder, which can displace the fundus to the right.
Extract:
A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right.
Question 2 of 5
Based on these findings, which of the following actions should the nurse take?
Correct Answer: B
Rationale: Assisting the client to void addresses a potentially full bladder, which can displace the uterus and cause a boggy fundus, contributing to uterine atony.
Extract:
A nurse is attending to a client 2 hours after a spontaneous vaginal birth and the client has saturated two perineal pads with blood within a 30-minute period.
Question 3 of 5
What should be the priority nursing intervention at this time?
Correct Answer: C
Rationale: Palpating the fundus is the priority to assess for uterine atony, a common cause of postpartum hemorrhage indicated by heavy bleeding.
Extract:
A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client's vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4° C (97.6° F).
Question 4 of 5
Which of the following is the priority nursing action?
Correct Answer: B
Rationale: Initiating IV access is the priority to address rapid blood loss and hypotension, allowing for fluid or blood administration.
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 5 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.