ATI RN
ATI RN Maternal Newborn 2023 II 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: A
Rationale: The correct answer is A: Escort the client to the bathroom. This action should be taken first to address the immediate need of the client for toileting. It promotes the client's comfort, maintains their dignity, and prevents potential complications like urinary retention. Option B (Offer the client a sitz bath) and C (Pour warm water over the client's perineum) are not priorities as they do not address the client's urgent need for toileting. Option D (Insert a urinary catheter) is an invasive procedure and should not be the first action unless indicated for a specific medical reason. Options E and F (None) are not appropriate as there is a clear immediate need that requires action.
Extract:
A nurse is assessing a client who is 1 hr postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding.
Question 2 of 5
Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Massage the client's fundus. This is the first action the nurse should take after childbirth to prevent postpartum hemorrhage by ensuring the uterus contracts and expels clots. Providing oxygen (
A) is important but not the priority. Emptying the bladder (
B) can help prevent uterine atony, but massaging the fundus is more urgent. Administering oxytocin (
C) can also help prevent hemorrhage, but fundal massage is the initial step.
Extract:
A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique.
Question 3 of 5
Which of the following information should the nurse include?
Correct Answer: B
Rationale: The correct answer is B because it addresses a potentially serious issue that requires immediate attention - dark red discoloration at the tip of the baby's penis could indicate compromised blood flow and potential necrosis. This information is crucial for the parent to be aware of to prevent any complications.
The other choices are incorrect because:
A: Yellow exudate forming at the surgical site in 24 hours is normal post-circumcision and does not warrant immediate notification to the provider.
C: Ensuring a snug diaper fit is important for comfort and preventing leakage, but it is not as critical as identifying signs of compromised blood flow.
D: The Plastibell is typically removed after a few days, not 4 hours after the procedure. Providing this misinformation could cause unnecessary concern for the parent.
Extract:
A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr. ago.
Question 4 of 5
Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply.)
Correct Answer: C, D, E
Rationale:
Correct Answer: C, D, E
Rationale:
C: Labor induction with oxytocin increases the risk of postpartum hemorrhage due to uterine hyperstimulation leading to poor uterine muscle contractions.
D: History of uterine atony indicates weak uterine muscles, which can result in ineffective contraction post-delivery, leading to hemorrhage.
E: Vacuum-assisted delivery can cause trauma to the birth canal and uterus, increasing the risk of postpartum hemorrhage.
Summary of Incorrect
Choices:
A: Newborn weight is not a direct risk factor for postpartum hemorrhage.
B: History of human papillomavirus does not predispose to postpartum hemorrhage.
F, G: No information provided.
Extract:
A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception.
Question 5 of 5
Which of the following instructions should the nurse include?
Correct Answer: A
Rationale:
Rationale:
Choice A is correct because if the diaphragm does not fit properly, it may not effectively prevent pregnancy. The nurse should advise the individual to have their provider refit them for a new diaphragm to ensure proper sizing and fit. This is crucial for the diaphragm to be effective in preventing pregnancy.
Summary:
Choices B, C, and D are incorrect. Keeping the diaphragm in place for a specific time after intercourse, using oil-based lubricants, and storing the diaphragm in sterile water are not recommended instructions for diaphragm use and may lead to inefficacy or health risks.