ATI RN
ATI Custom PNU Maternity Fall 2023 Questions
Extract:
Duplicate of Question 13: A nurse is caring for a client who is postpartum.
Question 1 of 5
Which of the following findings is an indication for the nurse to administer Rho(D) immune globulin?
Correct Answer: A
Rationale: The correct answer is A. Rho(
D) immune globulin is administered to Rh-negative mothers when the newborn is Rh-positive to prevent Rh incompatibility reactions. Rh incompatibility can occur if fetal blood enters the maternal circulation during pregnancy or delivery, causing the mother to develop antibodies against the Rh antigen. This can lead to hemolytic disease of the newborn in subsequent pregnancies.
Choices B, C, and D do not present a risk for Rh incompatibility as there is no exposure to Rh-positive blood for an Rh-negative mother.
Therefore, administering Rho(
D) immune globulin in those situations would not be necessary to prevent Rh sensitization.
Extract:
Vital Signs: 0800: Temperature 36.6°C (97.9°F), Pulse 88/min, Respirations 20/min, BP 179/99 mm Hg. 0815: Pulse 82/min, Respirations 16/min, BP 168/104 mm Hg. 0830: Pulse 81/min, Respirations 16/min, BP 170/101 mm Hg. Medical History: Gravida 3 Para 2, 32 weeks gestation, Allergies: Penicillin, Height 5'4, Weight 80.7 kg (178 lb), BMI 30.6, 6 lb weight gain in 2 weeks. Client reports 5-day headache, blurred vision, dizziness, unrelieved by Tylenol, swelling of feet/fingers, 2+ pitting edema, DTR 3+, FHT 148.
Question 2 of 5
Which of the following findings should the nurse report to the provider?
Correct Answer: C,D,E
Rationale: The nurse should report weight, visual disturbances, and blood pressure to the provider as they indicate potential health issues. Weight changes can signal fluid retention or malnutrition. Visual disturbances may signify neurological or ocular problems. Abnormal blood pressure levels can indicate cardiovascular issues or preeclampsia. Respirations, fetal heart rate, and deep tendon reflexes are typically monitored during routine assessments and don't necessarily require immediate reporting unless significantly abnormal.
Extract:
A nurse is reinforcing teaching with a new mother about the purpose of administering vitamin K to her newborn following delivery.
Question 3 of 5
The nurse should explain that the purpose of administering vitamin K is to prevent which of the following complications?
Correct Answer: A
Rationale: The correct answer is A: Bleeding. Vitamin K is essential for the production of clotting factors in the liver, which helps prevent bleeding disorders like hemorrhage in newborns. Hyperbilirubinemia is managed with phototherapy, not vitamin K. Potassium deficiency is unrelated to vitamin K administration. Infection prevention is not a primary purpose of vitamin K administration.
Extract:
A nurse is assisting a client with breastfeeding her newborn.
Question 4 of 5
The nurse should explain that which of the following reflexes will initiate sucking?
Correct Answer: A
Rationale: The correct answer is A: Rooting. When the cheek or lip is touched, the infant turns the head toward the stimulus and opens the mouth to suck. This reflex helps initiate sucking during breastfeeding. Moro reflex (
B) is a startle reflex, stepping reflex (
C) is for walking, and Babinski reflex (
D) is for assessing neurological function.
Choices E, F, G are not applicable.
Extract:
Question 5 of 5
Which of the following reflects the normal sequence of postpartum vaginal discharge?
Correct Answer: D
Rationale: The correct sequence is Lochia rubra, lochia serosa, lochia alba. Lochia rubra consists of blood and tissue debris, lasting for the first 3-4 days postpartum. Lochia serosa is pinkish or brownish and persists from days 4-10. Lochia alba is the final stage, yellowish-white discharge lasting up to 6 weeks. This sequence reflects the normal progression of postpartum vaginal discharge, starting with the presence of blood and ending with a lighter-colored discharge as the healing process progresses.
Choice D is correct.
Choices A, B, and C have the sequence of colors in the incorrect order, not following the typical progression of postpartum discharge.