ATI RN
ATI RN Maternal Newborn Updated 2023 Questions
Extract:
A client who is postpartum and has a perineal laceration.
Question 1 of 5
Which of the following findings places the client at risk for delayed wound healing?
Correct Answer: A
Rationale: The correct answer is A because changing the perineal pad only once daily can lead to increased moisture and potential for infection, thus delaying wound healing.
Choice B, using witch hazel pads, can actually promote wound healing due to its anti-inflammatory properties.
Choice C, cleaning the perineum with a squeeze bottle, promotes hygiene and wound healing.
Choice D, a well-approximated suture line, indicates good wound closure and does not place the client at risk for delayed healing.
Extract:
A client who delivered by cesarean birth 6 hr ago.
Question 2 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 client who is in labor and experiences abruptio placenta.
Question 3 of 5
Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Uterine tenderness. In the context of pregnancy, uterine tenderness may indicate a potential issue such as uterine infection or preterm labor. It is important for the nurse to assess this finding further to ensure the safety of the mother and baby. Hypertension (choice
A) may indicate preeclampsia, fetal tachycardia (choice
C) may suggest fetal distress, and leukorrhea (choice
D) is a common finding in pregnancy.
Choices E, F, and G are not provided.
Extract:
A client who is at 28 weeks of gestation and received no immunizations during childhood.
Question 4 of 5
Which of the following vaccines should the nurse plan to administer?
Correct Answer: C
Rationale: The correct answer is C: Tetanus. Tetanus vaccine should be administered routinely to prevent tetanus, a serious bacterial infection. The other choices are incorrect because: A: Human papillomavirus vaccine is typically given to prevent HPV-related cancers; B: Rubella vaccine is given to prevent rubella, a viral infection that can cause birth defects; D: Varicella vaccine is given to prevent chickenpox, a viral infection. In this case, the nurse should plan to administer the tetanus vaccine for routine preventive care.
Extract:
A client who is in labor and has a spontaneous rupture of membranes. The nurse notes that the umbilical cord is protruding from the client's vagina.
Question 5 of 5
After calling for help, which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct action is A: Use fingers to exert upward pressure on the presenting part. This is the first step in managing a prolapsed cord to alleviate pressure on the cord and prevent fetal hypoxia. Immediate action is crucial in this emergency situation. Administering tocolytic medication (
B) is not the priority as it does not address the immediate risk to the fetus. Applying oxygen via facemask (
C) is important but secondary to relieving cord compression. Wrapping the cord in a sterile towel (
D) is not recommended as it can further compress the cord.