a nurse is admitting a client who is at 33 weeks of gestation and has a diagnosis of placenta previa which of the following is the priority nursing ac
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ATI RN

ATI Maternal Newborn Proctored Exam 2023

1. 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.

2. 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?

Correct answer: C

Rationale: Preeclampsia is characterized by elevated blood pressure, proteinuria, and sometimes edema. Hypertension is a key sign of preeclampsia, and if present, further evaluation and monitoring are necessary to prevent complications for both the mother and the fetus.

3. 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?

Correct answer: C

Rationale: Polyhydramnios refers to the presence of an excessive amount of amniotic fluid around the fetus. This condition can result from various causes, such as maternal diabetes, fetal anomalies, or genetic disorders. It can lead to complications during pregnancy and delivery, such as preterm labor, placental abruption, or fetal malpresentation. Understanding this diagnosis is crucial for providing appropriate care and monitoring to ensure the best outcomes for both the mother and the fetus.

4. 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?

Correct answer: B

Rationale: Offering the client the option to view products of conception after an inevitable abortion can provide closure and support the grieving process. It allows the client to have a visual confirmation of the pregnancy loss, which can aid in emotional healing. Administering oxygen is not a priority in this scenario as there is no indication of respiratory distress. Instructing the client to increase potassium-rich foods is not directly related to managing an inevitable abortion. Bed rest may be recommended, but offering the option to view products of conception is a more appropriate intervention at this time.

5. A woman at 38 weeks of gestation and in early labor with ruptured membranes has an oral temperature of 38.9�C (102�F). Besides notifying the provider, which of the following is an appropriate nursing action?

Correct answer: C

Rationale: In a pregnant woman with a temperature of 38.9�C (102�F) in early labor with ruptured membranes, assessing the odor of the amniotic fluid is crucial. Foul-smelling or malodorous amniotic fluid could indicate infection, such as chorioamnionitis, which poses risks to both the woman and the fetus. This assessment can help in determining if an infection is present and prompt appropriate interventions. Rechecking the temperature, administering glucocorticoids, or preparing for an emergency cesarean section are not the most immediate or appropriate actions in this scenario.

Similar Questions

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?
A client with preterm labor is being admitted. The nurse anticipates a prescription by the provider for which of the following medications?
During the admission assessment of a client at 38 weeks of gestation with severe preeclampsia, what would the nurse expect as a finding?
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?
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?

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