ATI RN
ATI RN Maternal Newborn Updated 2023 Questions
Extract:
A client who is at 32 weeks of gestation and has placenta previa exhibiting a large amount of vaginal bleeding.
Question 1 of 5
Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct action for the nurse to take is to obtain serial hemoglobin and hematocrit levels. This is important for monitoring the patient's blood loss and hemodynamic status after childbirth. Serial monitoring helps in early detection of postpartum hemorrhage and guides appropriate interventions. Giving oxytocin 20 units IV bolus (choice
A) is contraindicated as it can cause severe adverse effects like hypotension and cardiac arrhythmias. Performing a fundal massage (choice
B) is a potential intervention for uterine atony but assessing for abdominal tenderness (choice
C) would be more appropriate to identify possible causes of pain.
Therefore, obtaining serial hemoglobin and hematocrit levels is the most appropriate action to assess and manage postpartum hemorrhage effectively.
Extract:
A client in the postpartum unit.
Question 2 of 5
Which of the following goals should the nurse identify for the client to accomplish during the taking-in phase of postpartum adjustment?
Correct Answer: D
Rationale: During the taking-in phase of postpartum adjustment, the focus is on the mother's own physical recovery and well-being.
Therefore, the most appropriate goal for the nurse to identify during this phase is D: The client will have adequate nutritional intake. This is crucial for the mother's own health and healing after childbirth. Proper nutrition supports her energy levels, helps with tissue repair, and aids in milk production if she chooses to breastfeed. The other choices are not as relevant during this phase. A and B are more related to infant care and safety, which are typically addressed in the later phases of postpartum adjustment. C involves family dynamics, which may be more pertinent in the later postpartum phases when the mother is more emotionally ready to focus on family roles.
Extract:
A client who is in labor and has received epidural analgesia.
Question 3 of 5
Which of the following findings should the nurse recognize and document as an adverse effect of epidural analgesia?
Correct Answer: A
Rationale: The correct answer is A: Hypotension. This is a known adverse effect of epidural analgesia due to sympathetic blockade leading to vasodilation. It can cause decreased blood pressure and compromise perfusion. Polyuria is not a typical effect of epidural analgesia. Fetal heart rate and maternal temperature are not directly related to the adverse effects of epidural analgesia.
Extract:
A newborn who is 2 hr old.
Question 4 of 5
Which of the following findings is an indication of hypoglycemia? (Select all that apply.)
Correct Answer: B,D,E
Rationale: The correct indications of hypoglycemia are jitteriness (
B), hypotonia (
D), and temperature instability (E). Jitteriness is a common sign of low blood sugar levels. Hypotonia refers to decreased muscle tone, often seen in infants with hypoglycemia. Temperature instability can occur due to the body's inability to regulate temperature when glucose levels are low. Abdominal distention (
A) and acrocyanosis (
C) are not typical signs of hypoglycemia and are more likely associated with other conditions.
Extract:
A client who is in labor and has a prescription for spinal anesthesia.
Question 5 of 5
Which of the following findings indicates that the IV bolus was effective?
Correct Answer: C
Rationale: The correct answer is C: Blood pressure 110/70 mm Hg. This finding indicates the IV bolus was effective because it signifies adequate perfusion and hemodynamic stability. A stable blood pressure within normal range suggests that the medication administered through the IV bolus is successfully supporting cardiac output and blood flow.
Choice A is incorrect as perineal pain is not necessarily a direct indicator of the effectiveness of the IV bolus.
Choice B, increased urinary output, could be a positive sign but does not directly confirm the effectiveness of the IV bolus in this situation.
Choice D, relief of pruritus, is also not a direct indicator of the IV bolus efficacy in this context.