ATI RN
ATI RN Maternal Newborn 2023 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: B
Rationale: The correct action for the nurse to take first is to assist the client to the bathroom (choice
B). This is the priority because it addresses the immediate need for the client's elimination. By assisting the client to the bathroom, the nurse ensures the client's comfort and dignity while also promoting their physical well-being. Inserting a urinary catheter (choice
A) should only be done if the client is unable to void on their own after other interventions. Offering a sitz bath (choice
C) and pouring warm water over the perineum (choice
D) may be helpful for comfort but do not address the urgent need for elimination.
Extract:
A nurse is assessing a client who is 3 days postpartum.
Question 2 of 5
Which of the following findings should the nurse report to the provider?
Correct Answer: B
Rationale: The correct answer is B: Cool clammy skin. This finding may indicate poor perfusion or shock, which could be concerning postpartum. The nurse should report this to the provider promptly for further evaluation and intervention.
A: BP 120/70 mm Hg is within normal range for postpartum, so it does not require immediate reporting.
C: Moderate lochia serosa is expected in the early postpartum period, so it is not a concerning finding that requires immediate reporting.
D: Heart rate of 89/min is slightly elevated but not critically high, so it does not necessitate immediate reporting.
In summary, the other choices are not as urgent or abnormal as cool clammy skin, which may indicate a more serious issue requiring prompt attention.
Extract:
A nurse is planning care for a client who is 1 hr postpartum and has peripartum cardiomyopathy.
Question 3 of 5
Which of the following actions should the nurse plan to take?
Correct Answer: D
Rationale: The correct answer is D: Restrict daily oral fluid intake. This action is important for patients with heart failure to prevent fluid overload. Administering an IV bolus of lactated Ringer's (
A) can exacerbate fluid overload. Obtaining misoprostol (
B) is not relevant to managing heart failure. Assessing blood pressure twice daily (
C) is important but not the priority.
Extract:
A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation.
Question 4 of 5
Which of the following findings should the nurse identify as a contraindication to the use of a suppository?
Correct Answer: B
Rationale: The correct answer is B: Third-degree perineal laceration. This is a contraindication to using a suppository because the insertion of a suppository may cause further trauma or discomfort to the area, delaying the healing process and increasing the risk of infection. Vaginal candidiasis (choice
A) is not a contraindication as the suppository can actually be used to treat this condition. Abdominal distention (choice
C) and afterpains (choice
D) are not direct contraindications to using a suppository and can be managed separately.
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 5 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.