ATI RN
ATI RN Maternal Newborn Updated 2023 Questions
Extract:
A client who is in the third stage of labor and has a prescription for IV oxytocin administration following expulsion of the placenta.
Question 1 of 5
Which of the following clinical manifestations should the nurse expect as a therapeutic effect of the medication?
Correct Answer: B
Rationale: The correct answer is B: The client's fundus is firm and midline. This is the expected therapeutic effect after childbirth as the uterus contracts to reduce bleeding and return to its normal size. A firm and midline fundus indicates proper uterine contraction and involution.
Choice A is incorrect as vaginal fullness is not a typical therapeutic effect of medication.
Choice C suggests excessive bleeding, which is not a desired outcome.
Choice D is irrelevant to postpartum care.
Extract:
A client who is 1 hr postpartum and has preeclampsia without severe features.
Question 2 of 5
Which of the following actions should the nurse plan to take?
Correct Answer: B
Rationale: The correct answer is B: Assess for edema. It is important for the nurse to assess for edema as it can indicate fluid overload or renal dysfunction, both of which require prompt intervention. Edema assessment involves checking for swelling in the extremities, pitting edema, and monitoring intake and output. Obtaining a prescription for misoprostol (
A) is not necessary without a specific indication. Restricting daily oral fluid intake (
C) could be harmful, especially if the patient is already dehydrated. Administering an IV bolus of lactated Ringer's (
D) is not appropriate without a physician's order and assessment indicating the need for fluid resuscitation.
Extract:
A client who delivered by cesarean birth 6 hr ago.
Question 3 of 5
The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Administer 500 mL lactated Ringer's IV bolus. This action is necessary to address potential hypovolemia due to the steady vaginal bleeding. Lactated Ringer's solution helps restore intravascular volume and maintain perfusion. Evaluating urinary output (
A) is important but not the priority when immediate action is needed. Replacing the surgical dressing (
B) is not the first step in managing ongoing bleeding. Applying an ice pack to the incision site (
C) is not indicated and may not address the underlying issue.
Extract:
A newborn who has a prescription for a total serum bilirubin.
Question 4 of 5
Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct action is to puncture the lateral side of the heel for the procedure. This is because the lateral side of the heel is the recommended site for a heel stick, as it has fewer nerve endings and blood vessels, reducing the risk of injury and pain. Selecting a 21-gauge needle (option
A) is not specific to the procedure and may not be appropriate. Applying an alcohol pad after the procedure (option
B) is not recommended as it can cause unnecessary pain and irritation. Placing a cool cloth at the site before the procedure (option
C) is not necessary and may not be effective for pain relief. Puncturing the lateral side of the heel is the correct and most appropriate action for this procedure.
Extract:
A client who has a placenta previa.
Question 5 of 5
Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: Painless, vaginal bleeding. This finding is indicative of placenta previa, a condition where the placenta partially or completely covers the cervix, leading to painless vaginal bleeding. Uterine hypertonicity (
A) suggests uterine hyperstimulation, not typically associated with placenta previa. Persistent headache (
B) is more commonly seen in conditions like preeclampsia. A firm, rigid abdomen (
C) is characteristic of uterine rupture, not placenta previa. In summary, painless vaginal bleeding is a key sign of placenta previa, distinguishing it from the other options.