ATI RN
ATI Nur 232 Maternity Final Exam SP24 Questions
Extract:
A nurse is planning care for a patient who is 2 hours postpartum following a cesarean birth. The patient has a history of thromboembolic disease.
Question 1 of 5
Which nursing interventions should be included in the plan of care?
Correct Answer: D
Rationale: Ambulation promotes circulation, reducing the risk of thromboembolism in a patient with a history of the condition.
Extract:
A nurse is assessing a newborn immediately after a scheduled cesarean delivery.
Question 2 of 5
Which of the following assessments should be the nurse's priority?
Correct Answer: C
Rationale: Respiratory distress is the priority assessment post-cesarean due to the risk of transient tachypnea of the newborn.
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:
A nurse receives report about assigned clients at the start of the shift.
Question 4 of 5
Which of the following clients should the nurse plan to see first?
Correct Answer: D
Rationale: Pain 4 hours post-cesarean birth may indicate complications like infection or hemorrhage, requiring immediate assessment.
Extract:
Nurse's Notes (0700hrs): Fetal heart tones (FHT): 145/min, Uterine contractions every 2 minutes, lasting 80 seconds, moderate intensity. Vital Signs (0700hrs): Client reports low back pain and frequent urination since last night. Urination is painful and only a small amount is passed each time. Abdomen is soft and nontender. Vaginal examination: 2 cm dilated, 100% effaced, 0 station. Bloody mucus noted on sterile glove. Medical History: G2P1, 34 weeks pregnant, No known allergies, Previous pregnancy was full-term with no complications. Diagnostic Results (0700hrs): Place client on electronic fetal monitor, Administer IV fluids, Monitor vital signs every hour, Notify provider of any changes in client status. A 28-year-old female client is admitted to the labor and delivery unit at 0700hrs. She is 34 weeks pregnant and reports having low back pain and frequent urination since last night. She mentions that urination is painful and she can only pass a small amount each time.
Question 5 of 5
Given the client's symptoms and the progression of her condition, the nurse suspects that the client may be experiencing complications related to preterm labor and a possible urinary tract infection (UTI). For each characteristic in the table, select whether it is more likely to be associated with preterm labor, a urinary tract infection (UTI), or both. Each column must have at least one response option selected. Candidates can select as many options as apply for each column.
| Complication | Preterm Labor | Urinary Tract Infection (UTI) |
|---|---|---|
| Frequent urination | ||
| Low back pain | ||
| Temperature of 38.3°C (101°F) | ||
| Strong urge to push | ||
| Contractions every 1.5 minutes | ||
| Pain level of 8 on a scale of 0 to 10 |
Correct Answer: A: UTI, B: Both, C: UTI, D: Preterm Labor, E: Preterm Labor, F: Both
Rationale: Frequent urination is more likely associated with a UTI due to irritation of the urinary tract. Low back pain can be associated with both preterm labor (due to uterine contractions) and UTI (due to kidney involvement). A temperature of 38.3°C (101°F) is more likely associated with a UTI, as fever is a common symptom of infection. A strong urge to push is indicative of preterm labor as it suggests advanced labor progression. Contractions every 1.5 minutes are a clear sign of preterm labor. A pain level of 8 can be associated with both conditions due to severe contractions in labor or significant infection-related discomfort in UTI.