ATI RN
ATI Custom PNU Maternity Fall 2023 Questions
Extract:
A nurse is reinforcing teaching about comfort measures for breast engorgement with a client who is postpartum and is bottle feeding her newborn.
Question 1 of 5
Which of the following statements by the client indicates a need for further teaching?
Correct Answer: A
Rationale: The correct answer is A because stimulating nipples can lead to increased milk production, which may not be necessary or desirable. B is incorrect as ice packs can help with breast engorgement. C is incorrect as a snug fitting bra can provide support. D is incorrect as cabbage leaves can help with breast pain.
Extract:
A nurse is assisting in the care of a client who is to undergo an amniotomy.
Question 2 of 5
Which of the following is the priority nursing action following this procedure?
Correct Answer: A
Rationale: The correct answer is A: Check the fetal heart rate pattern. This is the priority nursing action because it assesses the well-being of the fetus immediately after a procedure that may impact fetal distress. Monitoring the fetal heart rate helps identify any potential complications and guides further interventions. Evaluating for signs of infection (
B) is important but not the immediate priority post-procedure. Taking the client's temperature (
C) and observing amniotic fluid (
D) are important assessments but do not directly address fetal well-being.
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 3 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 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 4 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 is assisting with the care of a client who is using paced breathing during the first stage of labor. The client says she feels lightheaded and her fingers are tingling.
Question 5 of 5
Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct action for the nurse to take is A: Assist the client to breathe into a paper bag or cupped hand. This is appropriate for a client experiencing hyperventilation, as breathing into a paper bag helps rebreathe exhaled carbon dioxide, which can help normalize the client's breathing pattern. Option B is incorrect as it can exacerbate hyperventilation by increasing the respiratory rate further. Option C is incorrect as it is not a recommended intervention for hyperventilation. Option D is incorrect as administering oxygen may not address the underlying issue of hyperventilation.