ATI RN
ATI RN Maternal Newborn Updated 2023 Questions
Extract:
A client who is in labor and has a prescription for spinal anesthesia.
Question 1 of 4
Which of the following findings indicates that the IV bolus was effective?
Correct Answer: C
Rationale: The correct answer is C: Blood pressure 110/70 mm Hg. This finding indicates the IV bolus was effective because it signifies adequate perfusion and hemodynamic stability. A stable blood pressure within normal range suggests that the medication administered through the IV bolus is successfully supporting cardiac output and blood flow.
Choice A is incorrect as perineal pain is not necessarily a direct indicator of the effectiveness of the IV bolus.
Choice B, increased urinary output, could be a positive sign but does not directly confirm the effectiveness of the IV bolus in this situation.
Choice D, relief of pruritus, is also not a direct indicator of the IV bolus efficacy in this context.
Extract:
A newborn immediately following birth.
Question 2 of 4
How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or an indication that the client's condition is worsening.
| Finding | Unrelated to diagnosis | Indication client's condition is improving | Indication client's condition is worsening |
|---|---|---|---|
| Color: Consistent with genetic background - Unrelated | |||
| Axillary temperature 36.3° C (97.4°F), Reflex irritability: cry - Improving | |||
| Muscle tone: flaccid - Worsening | |||
| Respiration effort: good cry - Improving | |||
| Heart rate 140/min - Improving |
Correct Answer: A,B,C,D,E
Rationale:
The correct answer is A,B,C,D,E.
A: Color consistent with genetic background is unrelated to the diagnosis as it does not provide any direct information about the client's condition.
B: Axillary temperature 36.3°C, Reflex irritability: cry are indications that the client's condition is improving.
C: Muscle tone flaccid is an indication that the client's condition is worsening.
D: Respiration effort: good cry is an indication that the client's condition is improving.
E: Heart rate 140/min is an indication that the client's condition is improving.
Extract:
A client who is at 15 weeks of gestation during a routine prenatal visit.
Question 3 of 4
Which of the following findings should the nurse identify as an indication of a potential complication of pregnancy? Select all that apply.
Correct Answer: D,E,F
Rationale: The correct answers are D (Weight), E (Heart rate), and F (Urine-specific gravity). Weight gain outside the recommended range can indicate conditions like preeclampsia or gestational diabetes. Abnormal heart rate may suggest cardiac issues or preeclampsia. Changes in urine-specific gravity can show dehydration or kidney problems.
Choices A, B, C, and G are not direct indicators of potential pregnancy complications, though they can be affected by such complications indirectly.
Extract:
A postpartum client who delivered vaginally 8 hr ago.
Question 4 of 4
Select the 3 findings that require immediate follow-up.
Correct Answer: B,C,D
Rationale: The correct findings that require immediate follow-up are B: Lateral deviation of the uterus, C: Large amount of lochia rubra, and D: Uterine tone soft. Lateral deviation of the uterus could indicate a uterine anomaly or complication post-delivery. Large amount of lochia rubra may suggest excessive bleeding, which needs to be assessed promptly. Soft uterine tone can be a sign of uterine atony, a serious postpartum complication. Peripheral edema, soft breasts, low deep tendon reflexes, and mild pain rating do not typically require immediate intervention or follow-up.
Extract:
A newborn who was born at 39 weeks of gestation and is 36 hours old.
Question 5 of 4
Which of the following findings should the nurse report to the provider? Select all that apply.
Correct Answer: C,D,F
Rationale: The nurse should report findings that indicate potential issues requiring provider intervention. Coombs test result (
C) is crucial for detecting autoimmune hemolytic anemia. Abnormal sclera color (
D) may indicate liver dysfunction or jaundice. Intake and output (F) are essential for monitoring fluid balance. Glucose level (
A) is important but typically not an urgent concern. Head assessment finding (
B) may be relevant, but it depends on the specific abnormality. Heart rate (E) and mucous membrane assessment (G) are vital but generally do not require immediate provider notification.