ATI RN
ATI RN Maternal Newborn Latest Update. Questions
Extract:
“A nurse on an antepartum unit is caring for a client.
Exhibit1:
Nurses' Notes 0900:Client reports a small amount of bright red blood in their underwear upon
awakening. Client denies contractions or abdominal pain. External fetal monitor applied.
0930:Client passed large amount of bright red blood from vagina.
Denies pain Uterine tone soft and nontender to palpation.
contraction pattern, no contractions noted.
Fetal heart rate pattern: Fetal heart rate baseline 135/min.
Moderate variability. No decelerations noted.
Exhibit2:
Vital Signs 0900: Temperature 36.2°C (97.2° F) Pulse rate 78/min Respiratory rate 20/min Blood pressure
112/64 mm Hg Fetal heart rate 132/min Pulse rate 82/min Blood pressure 116/60 mm Hg Fetal heart
rate 160/min
Exhibit3:
Medical History. G4P3 30 weeks gestation Previous pregnancies delivered via cesarean section
Question 1 of 5
Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify it the intervention is indicated or contraindicated for the client.
| Potential Nursing Action | Indicated | Contraindicated | |
|---|---|---|---|
| Insert a large bore intravenous catheter. | |||
| Assess cervical dilation. | |||
| Weigh perineal pads. | |||
| Administer methotrexate. |
Correct Answer: A, C
Rationale: [,(0,0,1),(0,0,0),(0,0,0)]
Correct Answer: A, C
Rationale:
A: Inserting a large bore intravenous catheter is indicated for administering medications or fluids rapidly in emergency situations.
C: Weighing perineal pads is indicated to monitor postpartum hemorrhage.
Assessing cervical dilation (
B) is not necessary in this scenario. Administering methotrexate (
D) is not a nursing action.
Extract:
Question 2 of 5
A nurse is reviewing the prescriptions for a client who is pregnant and is taking digoxin. Which of the following actions should the nurse take to best evaluate the client’s medication adherence?
Correct Answer: D
Rationale: The correct answer is D: Check the client’s serum medication level. This is the best action to evaluate medication adherence for a client taking digoxin because digoxin has a narrow therapeutic range, and monitoring the serum level ensures the client is taking the medication as prescribed. Checking the serum level provides an objective measurement of how much digoxin is in the client's system, indicating adherence. Asking the client if they are taking the medication (choice
A) relies on self-reporting and may not be accurate. Assessing kidney function (choice
B) is important for digoxin monitoring but does not directly evaluate medication adherence. Determining the apical pulse rate (choice
C) is essential for digoxin therapy but does not directly assess adherence.
Question 3 of 5
A nurse is assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect?
Correct Answer: C
Rationale: The correct answer is C: Uterine tenderness. Postpartum endometritis is an infection of the uterine lining, causing inflammation and tenderness. This finding is characteristic of endometritis and requires immediate attention.
A: Temperature of 37.4°C is within normal range.
B: WBC count of 9,000/mm3 is within normal limits and may not indicate infection.
D: Scant lochia does not specifically indicate endometritis.
Therefore, the presence of uterine tenderness is the most significant finding in this scenario.
Question 4 of 5
A nurse is reviewing laboratory findings for a client who is at 20 weeks of gestation. Which of the following findings should the nurse report to the provider?
Correct Answer: D
Rationale: The correct answer is D: Fasting blood glucose 180 mg/dL (74 to 106 mg/dL). High blood glucose levels during pregnancy can indicate gestational diabetes, which poses risks to both the mother and the baby. The nurse should report this finding to the provider for further evaluation and management.
Choice A (Hematocrit 37%): Falls within the normal range for pregnancy and does not require immediate reporting.
Choice B (Creatinine 0.9 mg/dL): Within the normal range and does not indicate a concerning issue at this time.
Choice C (WBC count 11,000/mm3): Slightly elevated, but can be a normal physiological response during pregnancy and does not necessarily warrant immediate reporting.
In summary, the correct answer is D as it signifies a potential health concern that requires further assessment.
Choices A, B, and C are within normal ranges for pregnancy and do not pose immediate risks.
Question 5 of 5
A nurse is caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: Malodorous discharge. Trichomoniasis is a sexually transmitted infection caused by a parasite. Symptoms include a foul-smelling, yellow-green vaginal discharge. At 20 weeks of gestation, hormonal changes can increase vaginal discharge, but the malodorous aspect is specific to trichomoniasis.
Choice A is incorrect because trichomoniasis typically presents with a thin, frothy discharge, not thick and white.
Choice B, urinary frequency, is not a common symptom of trichomoniasis.
Choice C, vulva lesions, is more indicative of other STIs like herpes or syphilis.