a nurse in an antepartum unit is triaging clients which of the following clients should the nurse see first
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Nursing Elites

ATI RN

ATI Maternal Newborn Proctored Exam 2023

1. A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?

Correct answer: D

Rationale:

2. A client in labor at 40 weeks of gestation has saturated two perineal pads in the past 30 min. The nurse suspects placenta previa. Which of the following is an appropriate nursing action?

Correct answer: D

Rationale: In the scenario described, the client is experiencing heavy vaginal bleeding, which is concerning for placenta previa. The appropriate nursing action in this situation is to prepare for a cesarean birth. Placenta previa is a condition where the placenta partially or completely covers the cervix, which can lead to life-threatening bleeding during labor. It is crucial to avoid vaginal examinations or initiation of pushing as these actions can exacerbate bleeding. A magnesium sulfate infusion is not indicated in the management of placenta previa. Therefore, the priority intervention is to prepare for a cesarean birth to ensure the safety of the mother and the baby.

3. A client with preterm labor is being admitted. The nurse anticipates a prescription by the provider for which of the following medications?

Correct answer: B

Rationale: Indomethacin is used to delay premature labor by inhibiting uterine contractions. Prostaglandin E2, Methylergonovine, and Oxytocin are not typically used to manage preterm labor. Prostaglandin E2 can be used for cervical ripening and labor induction. Methylergonovine is used to prevent or control postpartum hemorrhage. Oxytocin is used for labor induction and augmentation of labor in term pregnancies.

4. A healthcare provider is preparing to administer an injection of Rho (D) immunoglobulin. The provider should understand that the purpose of this injection is to prevent which of the following newborn complications?

Correct answer: B

Rationale: Rho (D) immunoglobulin is given to Rh-negative individuals to prevent hemolytic disease of the newborn (HDN) caused by Rh incompatibility between the mother and the fetus. If an Rh-negative mother carries an Rh-positive fetus, there is a risk of sensitization during pregnancy or childbirth. Sensitization can lead to the production of antibodies that may attack Rh-positive red blood cells in future pregnancies, potentially causing severe hemolytic disease in the newborn, including complications like hydrops fetalis. Hydrops fetalis is a condition characterized by severe edema and fetal organ enlargement due to severe anemia and heart failure in the fetus.

5. A client with severe preeclampsia is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe to continue the infusion?

Correct answer: B

Rationale: A respiratory rate of 16/min within the normal range is an essential parameter to monitor when administering magnesium sulfate, as respiratory depression is a potential adverse effect. Diminished deep-tendon reflexes may indicate magnesium toxicity, warranting immediate intervention. A urine output of 50 mL in 4 hours is below the expected amount, suggesting decreased kidney perfusion, which can be exacerbated by magnesium sulfate. A heart rate of 56/min is bradycardic and may indicate magnesium toxicity, requiring assessment and possible discontinuation of the infusion.

Similar Questions

During an assessment, a nurse is evaluating a pregnant client for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?
A client at 10 weeks of gestation reports abdominal pain and moderate vaginal bleeding. The tentative diagnosis is inevitable abortion. Which of the following nursing interventions should be included in the plan of care?
A client is being assessed for postpartum infection. Which of the following findings should indicate to the healthcare provider that the client requires further evaluation for endometritis?
A client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios is found to have which of the following?
A client at 22 weeks of gestation with uncontrolled gestational diabetes mellitus may require medication. Which of the following medications would the provider likely prescribe?

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