ATI RN
ATI Custom PNU Maternity Fall 2023 Questions
Extract:
A nurse is assisting with monitoring a client who has preeclampsia and is receiving magnesium sulfate. The client's respiratory rate is 8 breaths/min and the nurse suspects toxic levels of magnesium.
Question 1 of 5
Which of the following should the nurse administer?
Correct Answer: A
Rationale: The correct answer is A: Calcium gluconate. In cases of calcium channel blocker toxicity, calcium gluconate is administered to counteract the effects of the overdose by increasing calcium levels and improving cardiac contractility. Flumazenil (
B) is used for benzodiazepine overdose, naloxone (
C) for opioid overdose, and protamine sulfate (
D) for heparin overdose. Calcium gluconate is the appropriate choice in this scenario due to the indication of calcium channel blocker toxicity.
Extract:
A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7°C (100°F); pulse rate 88/min; respiratory rate 18/min.
Question 2 of 5
Which of the following actions should the nurse perform?
Correct Answer: A
Rationale: The correct answer is A: Report the client's temperature elevation. This is the priority action as it indicates a potential infection, which can be life-threatening for the client and baby. Reporting allows for timely intervention. B is incorrect as it does not address the underlying issue. C is not indicated without further assessment. D is incorrect as it does not address the temperature elevation. Focusing on milk supply is not the priority.
Extract:
A nurse is reviewing laboratory results from a client who is at 28 weeks of gestation and has gestational diabetes. The nurse notes that blood glucose levels taken 1 hr following a meal range from 180 mg/dL to 250 mg/dL over the past week.
Question 3 of 5
Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct action for the nurse to take is C: Anticipate an order for insulin administration. This is the correct answer because insulin administration is indicated when a patient has uncontrolled diabetes with high blood sugar levels. The nurse should anticipate this order to help manage the patient's blood glucose levels effectively.
A: Increasing carbohydrates may further elevate blood sugar levels in a patient with uncontrolled diabetes.
B: A 2-hr oral glucose tolerance test is not the immediate action needed for a patient with uncontrolled diabetes.
D: Obtaining an HbA1c is useful for assessing long-term glucose control but does not address the immediate need for insulin administration.
Extract:
A nurse in a provider's office is caring for a client who is at 36 weeks of gestation and is scheduled for an amniocentesis. The client asks why she is having an ultrasound prior to the procedure.
Question 4 of 5
Which of the following responses by the nurse is appropriate?
Correct Answer: C
Rationale: The correct answer is C: "It assists in identifying the location of the placenta and fetus." This response is appropriate because ultrasound imaging can indeed help in determining the positions of both the placenta and fetus within the uterus, aiding in monitoring fetal growth and development.
Choice A is incorrect because ultrasound is not specifically a screening tool for spina bifida.
Choice B is incorrect as ultrasound is primarily used for assessing fetal growth and development, not estimating fetal age.
Choice D is incorrect because while ultrasound can detect multiple fetuses, its primary purpose is not to determine the number of fetuses present.
Extract:
A nurse is preparing to examine a post-term newborn immediately following delivery.
Question 5 of 5
Which of the following findings should she expect to observe? (Select all that apply.)
Correct Answer: C,E
Rationale: The correct findings the nurse should expect to observe in a newborn are cracked, peeling skin (choice
C) and vernix in the folds and creases (choice E). Cracked, peeling skin is a normal postnatal adaptation due to the loss of the protective vernix caseosa. Vernix in the folds and creases is also expected as it helps protect the skin from the amniotic fluid. Moro reflex (choice
A) is a newborn reflex that involves the spreading out and then drawing in of the infant's arms in response to a sensation of falling, so this is not a expected finding. Heel to ear maneuverability (choice
B) is not a typical newborn assessment, so it is an incorrect choice. Abundant lanugo (choice
D) is fine hair that covers a newborn's body and is typically shed before birth, so it is an incorrect finding for a newborn.