Questions 88

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ATI NUR223 Absection 4 Maternity Final Exam Questions

Extract:

A nurse is performing a physical examination of a client who is 1 day postpartum.


Question 1 of 5

Which of the following findings requires immediate intervention?

Correct Answer: A

Rationale: A displaced fundus suggests uterine atony or bladder distension, risking postpartum hemorrhage, requiring immediate intervention.

Extract:

A nurse is caring for an adolescent client who is gravida 1 and para 0, admitted at 38 weeks of gestation with a diagnosis of preeclampsia.


Question 2 of 5

Which of the following findings should the nurse identify as inconsistent with preeclampsia?

Correct Answer: B

Rationale: Deep tendon reflexes of +1 (normal or slightly increased) are inconsistent with preeclampsia, which typically presents with hyperreflexia due to central nervous system irritability.

Extract:

A nurse observes that a newborn has a pink trunk and head, bluish hands and feet, and flexed extremities 5 min after delivery. He has a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning.


Question 3 of 5

The nurse should document what Apgar score for this infant?

Correct Answer: 9

Rationale: Apgar score: Color (1), Heart rate (2), Respiratory effort (1), Muscle tone (1), Reflex irritability (2) = 9.

Extract:

A nurse is assessing a client who is pregnant for preeclampsia.


Question 4 of 5

Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

Correct Answer: D

Rationale: Elevated blood pressure (>140/90 mm Hg) is a hallmark of preeclampsia, necessitating further evaluation.

Extract:

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes variable decelerations in the fetal heart rate pattern.


Question 5 of 5

Which of the following actions should the nurse take first?

Correct Answer: B

Rationale: Variable decelerations suggest cord compression; the knee-chest position relieves pressure, improving fetal oxygenation.

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