ATI RN Maternal Newborn 2023 IV

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?

A. Apply an ice pack to the incision site. B. Administer 500 mL lactated Ringer's IV bolus C. Replace the surgical dressing D. Evaluate urinary output.

Correct Answer: B

Rationale: Administering a lactated Ringer's bolus restores fluid volume and stabilizes blood pressure due to persistent bleeding, addressing the immediate concern of fluid loss.

Extract:

A nurse is assessing a postpartum client who delivered vaginally 8 hr ago. Nurses' Notes: 0700: Breasts soft, nipples intact. Uterus firm, midline, at umbilicus. Moderate lochia rubra. Episiotomy well approximated, mild edema, ecchymosis. Pain 2/10. Able to void, no bladder distention. DTR 1+. Peripheral edema 2+ in legs. 1100: Breasts soft, nipples intact. Uterus soft, laterally deviated, 1 cm above umbilicus. Large lochia rubra. Pain 3/10. DTR 1+. Peripheral edema 2+ in legs. Vital Signs: 0700: Temp 36.2Â°C, Pulse 80/min, RR 16/min, BP 136/82 mmHg, SpO2 99%. 1100: Temp 37.2Â°C, Pulse 85/min, RR 18/min, BP 136/86 mmHg, SpO2 100%.

Question 2 of 5

Select the 3 findings that require immediate follow-up.

A. Uterine tone soft B. Blood pressure 136/86 mm Hg C. Peripheral edema 2+ bilateral lower extremities D. Large amount of lochia rubra E. Pain rating of 3 on a scale of 0 to 10 F. Breasts soft G. Lateral deviation of the uterus

Correct Answer: A, D, G

Rationale: A soft uterus (
A) risks postpartum hemorrhage. Large lochia rubra (
D) may indicate bleeding issues. Lateral uterine deviation (G) suggests a full bladder or complication. BP, edema, pain, and soft breasts are within normal limits.

Extract:

A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver.

Question 3 of 5

Which of the following actions should the nurse take?

A. Move the client onto their hands and knees. B. Press firmly on the client's suprapubic area. C. Apply pressure to the client's fundus. D. Assist the client in pulling their knees toward their abdomen.

Correct Answer: D

Rationale: The McRoberts maneuver involves flexing the clientâ€™s hips toward her abdomen to widen the pelvic outlet and relieve shoulder dystocia, making it the correct action.

Extract:

A nurse is caring for a client who is experiencing infertility and is requesting in vitro fertilization.

Question 4 of 5

Which of the following information should the nurse provide to the client?

A. Inform the client about the possible need for reduction of multiple fetuses. B. Instruct the client not to use donor oocytes. C. Instruct the client to avoid freezing embryos for possible use in the future. D. Inform the client that sperm will be introduced to the uterus during ovulation.

Correct Answer: A

Rationale: IVF increases the risk of multiple gestations, necessitating discussion about fetal reduction to reduce maternal and fetal risks. Donor oocytes and embryo freezing are options, and sperm is fertilized in vitro, not in utero.

Extract:

A nurse on the postpartum unit is caring for four clients.

Question 5 of 5

For which of the following clients should the nurse notify the provider?

A. A client who reports lochia rubra requiring changing perineal pads every 3 hr B. A client who reports abdominal cramping during breastfeeding C. A client who has a urinary output of 300 mL in 8 hr D. A client who is receiving magnesium sulfate and has absent deep tendon reflexes

Correct Answer: D

Rationale: Absent deep tendon reflexes in a client on magnesium sulfate indicate magnesium toxicity, requiring immediate provider notification to prevent respiratory or cardiac complications.

ATI RN Maternal Newborn 2023 IV | Nurselytic

Nurselytic

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