ATI RN
ATI RN Maternal Newborn Updated 2023 Questions
Extract:
A client who is at 28 weeks of gestation and received no immunizations during childhood.
Question 1 of 5
Which of the following vaccines should the nurse plan to administer?
Correct Answer: C
Rationale: The correct answer is C: Tetanus. Tetanus vaccine should be administered routinely to prevent tetanus, a serious bacterial infection. The other choices are incorrect because: A: Human papillomavirus vaccine is typically given to prevent HPV-related cancers; B: Rubella vaccine is given to prevent rubella, a viral infection that can cause birth defects; D: Varicella vaccine is given to prevent chickenpox, a viral infection. In this case, the nurse should plan to administer the tetanus vaccine for routine preventive care.
Extract:
A client who is at 35 weeks of gestation.
Question 2 of 5
Which of the following findings should indicate to the nurse the need for further diagnostic testing?
Correct Answer: C
Rationale: The correct answer is C. The reason further testing is needed when there are three fetal movements perceived by the client in a 20-minute period is that fetal movement assessment is crucial for assessing fetal well-being. A decrease or absence of fetal movements can indicate fetal distress, prompting the need for further evaluation to ensure the well-being of the fetus. In contrast, options A, B, and D describe normal or reassuring findings within the parameters of fetal heart rate monitoring and contractions, indicating fetal well-being. Option A shows a reassuring acceleration in fetal heart rate, option B indicates absence of late decelerations, and option D describes contractions that are not concerning if not felt by the client.
Extract:
A client who is at 32 weeks of gestation and has placenta previa exhibiting a large amount of vaginal bleeding.
Question 3 of 5
Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct action for the nurse to take is to obtain serial hemoglobin and hematocrit levels. This is important for monitoring the patient's blood loss and hemodynamic status after childbirth. Serial monitoring helps in early detection of postpartum hemorrhage and guides appropriate interventions. Giving oxytocin 20 units IV bolus (choice
A) is contraindicated as it can cause severe adverse effects like hypotension and cardiac arrhythmias. Performing a fundal massage (choice
B) is a potential intervention for uterine atony but assessing for abdominal tenderness (choice
C) would be more appropriate to identify possible causes of pain.
Therefore, obtaining serial hemoglobin and hematocrit levels is the most appropriate action to assess and manage postpartum hemorrhage effectively.
Extract:
A client who is 6 hr postpartum and has endometritis.
Question 4 of 5
Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Uterine tenderness. This finding is indicative of a possible infection or retained products of conception postpartum. Uterine tenderness may suggest endometritis, which requires prompt assessment and treatment. The other choices are incorrect because: A: WBC count within normal range. C: Scant lochia can be normal in the early postpartum period. D: Mild temperature elevation is common postpartum due to hormonal changes.
Extract:
A client who is 6 hr postpartum and is saturating perineal pads every 10 to 15 min.
Question 5 of 5
Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Collect hemoglobin and hematocrit levels. This is the first action the nurse should take to assess the client's oxygen-carrying capacity and hydration status. It provides crucial data for determining the client's overall health status. Inserting an indwelling urinary catheter (
B) is not the priority unless indicated. Administering oxygen via face mask (
C) is important, but assessing the client's hemoglobin and hematocrit levels takes precedence. Preparing the client to receive a plasma expander (
D) should only be done after assessing the client's current status.