ATI LPN
ATI PN Maternal Newborn 2023 II Questions
Extract:
A nurse is collecting data from a newborn who was delivered at 40 weeks of gestation.
Question 1 of 5
Which of the following is an expected finding when eliciting reflexes from the newborn?
Correct Answer: C
Rationale: The palmar grasp reflex, where the newborn's fingers curl around the nurse's finger, is an expected and normal finding in newborns, indicating healthy neurological function.
Extract:
A nurse is caring for a client who is at 41 weeks of gestation.
Question 2 of 5
The nurse should understand that which of the following findings can indicate a prenatal complication in this client?
Correct Answer: D
Rationale: Blurred vision can indicate a serious prenatal complication such as preeclampsia, which is characterized by high blood pressure and can pose significant risks to both mother and baby if not managed properly.
Extract:
Vital Signs (0900): Temperature: 37° C (98.6° F), Heart rate: 90/min, Blood pressure: 158/100 mm Hg, Respiratory rate: 16/min. (1000): Oxygen saturation: 98% on room air, Heart rate: 95/min, Temperature: 37° C (98.6° F), Blood pressure: 162/110 mm Hg, Respiratory rate: 20/min. Diagnostic Results: Hct: 35% (33 to 47%), Hgb: 10 g/dL (11 to 16 g/dL), Urine: 2+ protein, Platelet count: 95,000/mm³ (150,000 to 400,000/mm³), Aspartate aminotransferase (AST): 200 units/L (0 to 35 units/L), Alanine aminotransferase (ALT): 25 units/L (4 to 36 units/L), Total bilirubin: 1.8 mg/dL (0.3 to 1 mg/dL). Medical History: The client is a 26-year-old primigravida at 28 weeks of gestation. She is obese and has no history of hypertension or diabetes mellitus. She presents with elevated blood pressure, peripheral edema, and headaches. Physical Examination Results: The client is alert and oriented to person, place, and time. Her heart rate is regular, and respirations are even and non-labored. She has 3+ deep tendon reflexes and +2 pitting edema of the bilateral lower extremities. The fetal heart rate (FHR) is 140/min with moderate variability.
Question 3 of 5
Complete the following sentence by using the lists of options. The nurse should first address the client's ___ followed by the client's ___ and ___
Correct Answer: B
Rationale: The nurse should first address the client's blood pressure followed by the client's headache and liver enzymes. High blood pressure indicates preeclampsia, requiring immediate intervention. Headache and elevated liver enzymes (AST 200 units/L) suggest severe preeclampsia complications.
Extract:
A nurse is reinforcing teaching with a client who is at 38 weeks of gestation and has a positive group B streptococcus B-hemolytic screening.
Question 4 of 5
Which of the following medications should the nurse discuss as the prophylaxis treatment during labor for this client?
Correct Answer: A
Rationale: Penicillin is the recommended prophylactic treatment for a client at 38 weeks of gestation with a positive group B streptococcus B-hemolytic screening. It is highly effective in preventing the transmission of group B strep from mother to baby during labor and delivery. Administering Penicillin reduces the risk of neonatal sepsis, pneumonia, and meningitis caused by group B strep.
Extract:
Nurses' Notes: At 0625, the client is alert and oriented, at 38 weeks of gestation, presenting to the labor and delivery unit for evaluation of fluid leaking from the vagina. The client states they felt a small gush of fluid and thinks their membranes have ruptured. At 0830, mild contractions are occurring 20 minutes apart, irregular, lasting 40 seconds. The client rates the pain as a 3 on a scale of 0 to 10. An electronic fetal monitor is applied. The client voided 50 mL of clear yellow urine in a bedpan. Mild contractions are now 15 minutes apart, irregular, lasting 30 seconds. The cervix is 2 cm dilated with 20% effacement. The client rates pain as a 4 on a scale of 0 to 10. The fetal heart rate (FHR) is 132/min with moderate variability.
Question 5 of 5
The nurse is assisting with planning care for the client. After review of the client's electronic medical record (EMR), which of the following interventions should the nurse recommend as anticipated, nonessential, or contraindicated?
| Options | Indicated | Non-Essential | Contraindicated |
|---|---|---|---|
| Encourage frequent ambulation | |||
| Ensure the client maintains a supine position while in bed | |||
| Check FHR every 30 min | |||
| Perform a Nitrazine test | |||
| Prepare the client for catheterization | |||
| Obtain CBC blood sample | |||
| Check the client's temperature every hour |
Correct Answer: A: Anticipated, B: Contraindicated, C: Anticipated, D: Anticipated, E: Nonessential, F: Nonessential, G: Anticipated
Rationale: A: Encourages labor progression. B: Can impede labor and fetal oxygenation. C: Ensures fetal well-being. D: Confirms rupture of membranes. E: Not needed with spontaneous voiding. F: No signs of infection. G: Monitors for infection post-rupture.