ATI LPN
ATI PN Maternal Newborn 2023 II Questions
Extract:
A nurse is reinforcing teaching about breastfeeding with the mother of a newborn.
Question 1 of 5
Which of the following instructions should the nurse include?
Correct Answer: C
Rationale: Ensuring the newborn empties the first breast allows them to receive the nutrient-rich hindmilk, which is crucial for growth.
Extract:
A nurse in a prenatal clinic is collecting data from a client who is at 26 weeks of gestation.
Question 2 of 5
Which of the following findings reported by the client should the nurse report to the provider?
Correct Answer: B
Rationale: Abdominal cramping at 26 weeks of gestation could indicate preterm labor or other complications, such as placental abruption. It’s a significant symptom that needs immediate medical attention.
Extract:
A nurse is reinforcing discharge teaching with a client who is pregnant and was treated for a urinary tract infection.
Question 3 of 5
Which of the following should the nurse include in the discharge instructions? (Select all that apply.)
Correct Answer: C,E
Rationale: Wearing cotton-crotch underwear is recommended because cotton is breathable and helps to keep the genital area dry, reducing the risk of infections. Refraining from taking bubble baths is advised, as the chemicals in bubble bath products can irritate the urethra and increase the risk of UTIs.
Extract:
Vital Signs 0700: Temperature: 36.2°C (97.2°F), Heart rate: 80/min, Respiratory rate: 16/min, Blood pressure: 136/82 mm Hg. 1100: Temperature: 37.2°C (99.0°F), Heart rate: 85/min, Respiratory rate: 18/min, Blood pressure: 136/86 mm Hg, Pulse oximetry: 99%. Nurses' Notes 0700: The client's breasts were soft, and nipples were intact. The uterus was palpated as firm, midline, and at the level of the umbilicus. There was a moderate amount of lochia rubra. The episiotomy site was well approximated with mild edema and ecchymosis. The client reported pain as 2 on a scale of 0 to 10. She was able to void spontaneously, with no bladder distention. Deep tendon reflexes were 1+. Peripheral edema was 2+ in bilateral lower extremities. 1100: The client's breasts remained soft, and nipples were intact. The uterus was palpated as soft with lateral deviation and 1 cm above the umbilicus. There was a large amount of lochia rubra. The episiotomy site was well approximated with mild edema and ecchymosis. The client reported pain as 3 on a scale of 0 to 10. Deep tendon reflexes were 1+. Peripheral edema was 2+ in bilateral lower extremities.
Question 4 of 5
Select the 3 findings that require immediate follow-up.
Correct Answer: B,F,G
Rationale: Lateral deviation of the uterus can indicate bladder distension, which can interfere with uterine contraction and increase the risk of postpartum hemorrhage. A soft uterine tone indicates uterine atony, which can lead to postpartum hemorrhage. A large amount of lochia rubra can be a sign of postpartum hemorrhage.
Extract:
Vital Signs (0610): Oral temperature: 36.6°C (97.9°F), Heart rate: 120/min, Respiratory rate: 22/min, Blood pressure: 86/48 mm Hg, SaO₂: 96% on room air. Nurses' Notes (0630): The client appears anxious and reports dizziness. She has pale skin and cool extremities. Her abdomen is soft and non-tender with no palpable contractions. She reports no vaginal bleeding or discharge. Deep tendon reflexes are 2+. Peripheral edema is 1+ in bilateral lower extremities. The client is also noted to have tachycardia. Diagnostic Results: Hematocrit (Hct): 25% (normal: >33%), Hemoglobin (Hgb): 9 g/dL (normal: >11 g/dL), Maternal blood type: B+, Platelet count: 110,000/mm³ (normal: 150,000 to 400,000/mm³), WBC count: 12,000/mm³ (normal: 5,000 to 10,000/mm³).
Question 5 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Action to Take
Potential Condition
Parameter to Monitor
Correct Answer: A
Rationale: An ectopic pregnancy is most likely due to the combination of symptoms: dizziness, pale skin, cool extremities, low blood pressure (86/48 mm Hg), and high heart rate (120/min). Actions: Administer methotrexate to stop embryo growth; insert a large-bore peripheral IV catheter to manage blood loss. Parameters: Monitor beta hCG levels to confirm diagnosis; monitor platelet count due to bleeding risk.