ATI RN
ATI Maternal Newborn Proctored Exam Latest Update Questions
Extract:
Question 1 of 5
Which preoperative nursing interventions should be included for a client who is scheduled to have an emergency cesarean birth?
Correct Answer: B
Rationale: The correct answer is B. Assessing vital signs every 15 minutes is crucial in an emergency cesarean birth to monitor the client's condition. Instructing the client about postoperative care ensures they are well-prepared. Alleviating anxiety is important for the client's emotional well-being. Inserting an indwelling catheter is also necessary for bladder emptying to prevent injury during surgery.
Choice A is incorrect because oxygen saturation monitoring is not typically a preoperative intervention for a cesarean birth, and administering pain medication may not be necessary preoperatively.
Choice C is incorrect as a sterile vaginal examination is not indicated before a cesarean birth, and assessing breath sounds does not directly relate to preoperative care for this procedure.
Choice D is incorrect because although anxiety management and indwelling catheter insertion are important, the rationale provided is not directly related to preoperative care for a cesarean birth.
Question 2 of 5
Which nursing instruction should be given to the breastfeeding mother regarding care of the breasts after discharge?
Correct Answer: C
Rationale: The correct answer is C. It is important to stimulate adequate milk production by pumping if the infant is not sucking or eating well, or if the breasts are not fully emptied. This helps maintain milk supply and prevents engorgement. Option A is incorrect as giving a bottle of formula does not effectively relieve engorgement and can lead to decreased milk production. Option B is incorrect as applying lotion to the nipples is not necessary and may introduce harmful microorganisms. Option D is incorrect as using soap can dry the nipples and lead to cracking, and giving formula is not the recommended solution for engorgement.
Question 3 of 5
A client in preterm labor is admitted to the hospital. Which classification of drugs should the nurse anticipate administering?
Correct Answer: A
Rationale: The correct answer is A:
Tocolytics.
Tocolytics are drugs used to inhibit uterine contractions and delay preterm labor. They help prevent premature birth and allow time for other interventions. Anticonvulsants (
B) are used to treat seizures, not preterm labor. Glucocorticoids (
C) are given to enhance fetal lung maturity in preterm labor, but do not inhibit contractions. Anti-infectives (
D) are used to treat infections, not preterm labor.
Therefore, tocolytics are the most appropriate choice in this scenario.
Question 4 of 5
Which of the following are probable signs, strongly indicating pregnancy?
Correct Answer: C
Rationale: The correct answer is C because Hegar's sign and Chadwick's sign are considered probable signs of pregnancy. Hegar's sign indicates softening of the lower uterine segment, a physiological change that typically occurs in pregnancy. Chadwick's sign refers to the bluish or purplish color of the cervix due to increased blood supply and estrogen levels in pregnancy. These signs are more specific to pregnancy compared to presumptive signs like quickening, which can be caused by other conditions. Ballottement is a technique used to assess fetal movement and position, not a sign indicating pregnancy certainty.
Therefore, choices A, B, and D are incorrect as they refer to presumptive signs or signs that could be caused by conditions other than pregnancy.
Question 5 of 5
Two hours after delivery the nurse assesses the client and documents that the fundus is soft, boggy, above the level of the umbilicus, and displaced to the right side. The nurse encourages the client to void. Which is the rationale for this nursing action?
Correct Answer: A
Rationale: The correct answer is A: A full bladder prevents normal contractions of the uterus. A full bladder can impede the involution process of the uterus by exerting pressure on it, inhibiting proper contraction. This can lead to postpartum hemorrhage and increased risk of retained placental fragments. Encouraging the client to void helps to relieve the pressure on the uterus, allowing it to contract effectively and aiding in the expulsion of lochia and prevention of complications.
Other choices are incorrect because:
B: An overdistended bladder may press against the episiotomy causing dehiscence - While this is a potential risk, it is not directly related to fundal assessment and contraction.
C: Distention of the bladder can cause urinary stasis and infection - While true, this is not the primary concern when assessing the fundus post-delivery.
D: It makes the client more comfortable when the fundus is massaged - Massaging the fundus is a separate intervention and does