ATI LPN
ATI PN Maternal Newborn 2023 II Questions
Extract:
A nurse is assisting with a pelvic examination of a client during their first prenatal visit.
Question 1 of 5
Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Instructing the client to bear down when the speculum is inserted is correct. Bearing down helps relax the pelvic muscles, making it easier to insert the speculum and perform the examination with minimal discomfort.
Extract:
A nurse is collecting data from a client who is 18 hr postpartum.
Question 2 of 5
Which of the following findings require the nurse to intervene?
Correct Answer: A
Rationale: Fundus located to the right of the umbilicus requires intervention. This can indicate a full bladder, which can inhibit uterine contraction and increase the risk of postpartum hemorrhage.
Extract:
Vital Signs: Heart rate: 132/min, Axillary temperature: 36° C (96.8° F), Respiratory rate: 72/min, Weight: 4,366 g (9 lb 10 oz). History and Physical: The newborn was delivered via spontaneous vaginal birth at 41 weeks of gestation. The mother is gravida 2 para 2 with a history of syphilis in the first trimester, treated with penicillin, and no reoccurrence during the pregnancy. The mother also reports intermittent cannabis use during pregnancy. Diagnostic Results: Blood type: A+, Venereal Disease Research Laboratory (VDRL): negative, Rapid Plasma Reagin (RPR): negative, Urine drug screen: Positive for marijuana, negative for opiates, cocaine, amphetamines, or barbiturates. Nurses' Notes: The newborn is lying in a bassinet, lightly swaddled. The newborn is noted to be jittery with a weak cry when disturbed. Extremities are mottled with acrocyanosis. Respirations are rapid and unlabored.
Question 3 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Correct Answer:
Rationale: Hypoglycemia is most likely given the newborn's jitteriness, weak cry, and mottled extremities. Actions: Feed the newborn to increase blood sugar; monitor phototherapy for jaundice. Parameters: Assess skin integrity; monitor bilirubin levels.
Extract:
A nurse is caring for a client who is at 41 weeks of gestation.
Question 4 of 5
The nurse should understand that which of the following findings can indicate a prenatal complication in this client?
Correct Answer: D
Rationale: Blurred vision can indicate a serious prenatal complication such as preeclampsia, which is characterized by high blood pressure and can pose significant risks to both mother and baby if not managed properly.
Extract:
Vital Signs (0610): Oral temperature: 36.6°C (97.9°F), Heart rate: 120/min, Respiratory rate: 22/min, Blood pressure: 86/48 mm Hg, SaO₂: 96% on room air. Nurses' Notes (0630): The client appears anxious and reports dizziness. She has pale skin and cool extremities. Her abdomen is soft and non-tender with no palpable contractions. She reports no vaginal bleeding or discharge. Deep tendon reflexes are 2+. Peripheral edema is 1+ in bilateral lower extremities. The client is also noted to have tachycardia. Diagnostic Results: Hematocrit (Hct): 25% (normal: >33%), Hemoglobin (Hgb): 9 g/dL (normal: >11 g/dL), Maternal blood type: B+, Platelet count: 110,000/mm³ (normal: 150,000 to 400,000/mm³), WBC count: 12,000/mm³ (normal: 5,000 to 10,000/mm³).
Question 5 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Correct Answer: A
Rationale: An ectopic pregnancy is most likely due to the combination of symptoms: dizziness, pale skin, cool extremities, low blood pressure (86/48 mm Hg), and high heart rate (120/min). Actions: Administer methotrexate to stop embryo growth; insert a large-bore peripheral IV catheter to manage blood loss. Parameters: Monitor beta hCG levels to confirm diagnosis; monitor platelet count due to bleeding risk.