ATI RN
ATI RN Maternal Newborn 2023 Questions
Extract:
A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage.
Question 1 of 5
Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct action for the nurse to take is to evaluate urinary output (
Choice
C). This is important post-surgery to assess renal function and fluid balance. Monitoring urine output can indicate adequate organ perfusion and hydration status. It helps in early detection of complications like renal failure. Applying an ice pack (
Choice
A) may be indicated for pain but is not the priority. Replacing the surgical dressing (
Choice
B) is important but not as crucial as evaluating urinary output. Administering IV bolus (
Choice
D) may be necessary in certain situations, but assessing urinary output should be done first to determine the need for fluid administration.
Extract:
A nurse is reviewing the prescriptions for a client who is pregnant and is taking digoxin.
Question 2 of 5
Which of the following actions should the nurse take to best evaluate the client's medication adherence?
Correct Answer: D
Rationale: The correct answer is D: Check the client's serum medication level. This is the best action to evaluate medication adherence because it directly measures the concentration of the medication in the client's bloodstream. If the medication level is within the therapeutic range, it indicates that the client is taking the medication as prescribed. If the level is too low or too high, it suggests non-adherence or potential issues with medication absorption or metabolism.
Choice A is incorrect as determining the client's apical pulse rate does not directly assess medication adherence.
Choice B is less reliable as clients may not always provide accurate information about their medication adherence.
Choice C is unrelated to evaluating medication adherence.
Extract:
A nurse is assessing a client who is 6 hr postpartum and has endometritis.
Question 3 of 5
Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: Uterine tenderness. This finding is indicative of postpartum endometritis, a common infection after childbirth. Uterine tenderness suggests inflammation of the uterine lining, which can lead to fever and other signs of infection. A high temperature (choice
A) can also be a sign of infection, but uterine tenderness is a more specific finding in this context. WBC count of 9,000/mm3 (choice
B) is within the normal range and does not necessarily indicate infection. Scant lochia (choice
C) refers to minimal postpartum bleeding, which is a normal finding.
Choices E, F, and G are not provided, so they are irrelevant.
Extract:
A nurse is assessing a client who is at 6 weeks of gestation and adheres to a vegan diet.
Question 4 of 5
Which of the following questions should the nurse ask to assess the client's dietary intake?
Correct Answer: C
Rationale: Rationale for choice C: Asking how much protein the client eats in a day assesses the client's overall dietary intake and can provide valuable information about their nutritional status. Protein is an essential macronutrient, and inadequate intake can lead to various health issues. By inquiring about protein consumption, the nurse can evaluate if the client is meeting their nutritional needs.
Rationale for other choices:
A: Asking about the last time the client ate meat is specific and may not give a comprehensive picture of their overall dietary habits.
B: Asking if the client has considered eating shellfish is too specific and does not address their current dietary intake.
D: Inquiring about a Vitamin C supplement is not directly related to assessing the client's overall dietary intake.
Extract:
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid.
Question 5 of 5
Which of the following actions should the nurse include in the plan of care?
Correct Answer: A
Rationale: The correct answer is A: Administer broad-spectrum antibiotics. This is essential in the plan of care to treat a suspected infection. Antibiotics can target a wide range of bacteria, covering potential pathogens until specific cultures can identify the causative organism. Cleansing the site with povidone-iodine (
B) is important for local hygiene but does not address systemic infection. Monitoring rectal temperature (
C) is a good assessment measure but does not actively treat infection. Preparing for surgical closure after 72 hr (
D) may be necessary but does not address the immediate need to manage infection.