ATI RN
ATI RN Maternal Newborn 2023 Exam 4 Questions
Extract:
A nurse is caring for a client who has bladder distention following a vaginal birth.
Question 1 of 5
Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: The nurse should assist the client to the bathroom first because it addresses the immediate need for toileting, ensuring comfort and preventing potential accidents. This action promotes the client's autonomy and dignity. Inserting a urinary catheter (
Choice
A) should not be the first step as it's an invasive procedure with potential complications. Offering a sitz bath (
Choice
B) and pouring warm water over the perineum (
Choice
D) are helpful for comfort but do not address the immediate need for toileting.
Extract:
A nurse is assessing a newborn whose mother had gestational diabetes mellitus.
Question 2 of 5
The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?
Correct Answer: A
Rationale: The correct answer is A: Jitteriness. Hypoglycemia is low blood sugar, leading to brain dysfunction. Jitteriness is a common early sign due to the brain's reliance on glucose for energy. Increased muscle tone (
B) and abdominal distention (
C) are not typical manifestations of hypoglycemia. Petechiae (
D) are tiny, flat, red or purple spots on the skin due to bleeding and are not associated with hypoglycemia.
Extract:
A nurse has been monitoring a client who gave birth vaginally 8 hours ago.
Question 3 of 5
Based on the nurse's notes at 0700 and 1100, select the three findings that necessitate immediate follow-up.
Correct Answer: B, C, E
Rationale: A BP of 136/86 mm Hg (
B) suggests possible hypertension, lateral deviation of the uterus (
C) may indicate a full bladder affecting uterine contraction, and large lochia rubra (E) could signal hemorrhage.
Extract:
A nurse is planning care for a client who is 1 hour postpartum and has peripartum cardiomyopathy.
Question 4 of 5
Which of the following actions should the nurse plan to take?
Correct Answer: C
Rationale: The correct answer is C: Restrict daily oral fluid intake. In a scenario where fluid restriction is necessary, the nurse should plan to limit the patient's oral fluid intake to help manage a specific condition such as heart failure or kidney disease. This action helps prevent fluid overload, which can lead to complications like edema and worsening of the patient's condition. Assessing blood pressure (
B) is important but not the most relevant action in this context. Administering an IV bolus of lactated Ringer's (
A) is not appropriate without a specific indication. Obtaining a prescription for misoprostol (
D) is not relevant to fluid management.
Extract:
A nurse is providing care to a client who is receiving an epidural block with an opioid analgesic.
Question 5 of 5
Which of the following findings should the nurse monitor as a potential adverse effect of the medication?
Correct Answer: C
Rationale: Hypotension is a known side effect of epidural analgesia due to sympathetic blockade.