ATI LPN
ATI LPN Maternal Newborn Questions
Extract:
A nurse is assisting with the care of a client who is in labor and has received nalbuphine hydrochloride.
Question 1 of 5
Which of the following manifestations should the nurse identify as an adverse effect of this medication?
Correct Answer: D
Rationale: Sedation is a common adverse effect of nalbuphine, an opioid analgesic, causing drowsiness or reduced alertness.
Extract:
A nurse is collecting data from a client who has hyperemesis gravidarum.
Question 2 of 5
Which of the following findings should the nurse anticipate?
Correct Answer: A
Rationale: Poor skin turgor indicates dehydration, a common consequence of severe vomiting in hyperemesis gravidarum.
Extract:
Medical History: 26-year-old primigravida at 28 weeks, obese, no hypertension or diabetes history, presents with elevated blood pressure, peripheral edema, headaches. Physical Examination: Alert, oriented, 3+ deep tendon reflexes, +2 pitting edema, FHR 140/min with moderate variability. Diagnostic Results: Hgb 10 g/dL, Hct 35%, Platelet count 95,000/mm3, AST 200 units/L, ALT 25 units/L, Total bilirubin 1.8 mg/dL, Urine 2+ protein. Vital Signs: BP 158/100 mm Hg (0900), 162/110 mm Hg (1000), HR 90-95/min, RR 16-20/min, Temp 37°C, O2 sat 96-98%.
Question 3 of 5
The nurse should first address the client's ___ followed by the client's ___
Correct Answer: A
Rationale: Severe hypertension (162/110 mm Hg) risks stroke and eclampsia, requiring immediate antihypertensive treatment, followed by addressing low platelet count (95,000/mm³) indicating HELLP syndrome and bleeding risk.
Extract:
Nurses' Notes: Client at 38 weeks, reports fluid leaking, suspects ruptured membranes. Mild contractions 20 min apart (0630), 15 min apart (0830). Cervix 2 cm dilated, 20% effaced. FHR 132/min with moderate variability. Vital Signs: Temp 37.1°C, HR 93-95/min, RR 13-15/min, BP 130/76-135/78 mm Hg, O2 sat 99-100%.
Question 4 of 5
After review of the client's electronic medical record (EMR), which of the following interventions should the nurse recommend as anticipated, nonessential, or contraindicated?
| Intervention | Anticipated | Nonessential | Contraindicated |
|---|---|---|---|
| Perform a Nitrazine test: Anticipated | |||
| Check client's temperature every hour: Nonessential | |||
| Check FHR every 30 min: Anticipated | |||
| Ensure the client maintains a supine position while in bed: Contraindicated | |||
| Prepare the client for catheterization: Nonessential | |||
| Encourage frequent ambulation: Anticipated |
Correct Answer: A,C,F
Rationale: Nitrazine test confirms ruptured membranes, FHR monitoring every 30 min ensures fetal well-being, and ambulation supports labor progression. Hourly temperature checks and catheterization are not necessary, and supine position risks hypotensive syndrome.
Extract:
Nurses' Notes: Newborn lightly swaddled, jittery, weak cry, mottled extremities, acrocyanosis, rapid respirations. History: Gravida 2 Para 2, vaginal birth at 41 weeks, maternal syphilis treated, intermittent cannabis use. Vital Signs: Temp 36°C, HR 132/min, RR 72/min, Weight 4,366 g. Diagnostic Results: Maternal blood type A+, RPR/VDRL negative, urine drug screen positive for marijuana.
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. Condition: ___ Actions: ___ Parameters: ___
Action to Take
Potential Condition
Parameter to Monitor
Correct Answer: A
Rationale: Jitteriness, weak cry, and large birth weight suggest hypoglycemia. Feeding stabilizes glucose, and capillary blood confirms diagnosis. Monitoring respiratory status and temperature assesses progress.