a nurse in an antepartum unit is triaging clients which of the following clients should the nurse see first
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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. When admitting a client at 33 weeks of gestation with a diagnosis of placenta previa, which action should the nurse prioritize?

Correct answer: D

Rationale: Placenta previa is a condition where the placenta partially or completely covers the cervix, leading to potential bleeding. When admitting a client with placenta previa, the priority is to assess the fetal well-being. Applying an external fetal monitor helps in continuous monitoring of the fetal heart rate and ensures timely detection of any distress or changes in the fetal status, which is crucial in managing this condition. While monitoring vaginal bleeding is important, identifying fetal well-being takes precedence in this situation.

3. When reviewing the arterial blood gas values for a client, a nurse notes a pH of 7.32, PaCO2 of 48 mm Hg, and HCO3 of 23 mEq/L. What does this indicate about the acid-base balance?

Correct answer: A

Rationale: The given values suggest respiratory acidosis. In respiratory acidosis, the pH is low (<7.35), PaCO2 is high (>45 mm Hg), and the HCO3 is normal or slightly elevated. In this scenario, the low pH (7.32) and high PaCO2 (48 mm Hg) indicate respiratory acidosis, where there is an excess of carbon dioxide in the blood, leading to acidification of the body fluids.

4. A healthcare provider is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the provider immediately?

Correct answer: D

Rationale: The correct answer is a client who has a diagnosis of preeclampsia reporting epigastric pain and an unresolved headache. These symptoms indicate severe preeclampsia, which requires immediate medical attention due to the potential risks of complications such as HELLP syndrome or eclampsia. The other options describe concerning situations but do not represent immediate life-threatening conditions like those seen in severe preeclampsia.

5. A newborn is born to a mother with poorly controlled type 2 diabetes. The newborn is macrosomic and presents with respiratory distress syndrome. The most likely cause of the respiratory distress is which of the following?

Correct answer: A

Rationale: The correct answer is hyperinsulinemia. In infants born to mothers with poorly controlled diabetes, the excess glucose crosses the placenta, leading to fetal hyperglycemia. This results in fetal hyperinsulinemia, which in turn can cause macrosomia (large birth weight), increasing the risk of respiratory distress syndrome due to the immature lungs' inability to handle the increased workload. Hyperinsulinemia, not increased deposits of fat, brachial plexus injury, or increased blood viscosity, is the most likely cause of respiratory distress in this scenario.

Similar Questions

A nurse receives report about assigned clients at the start of the shift. Which of the following clients should the nurse plan to see first?
A client who experienced a cesarean birth due to dysfunctional labor expresses disappointment for not having a natural childbirth. Which response should the nurse make?
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?
A client in a prenatal clinic is being taught by a nurse in her second trimester with a new diagnosis of gestational diabetes. Which of the following client statements indicates a need for further teaching?
A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

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