a nurse is assessing a client who is 4 hr postpartum following a vaginal delivery which of the following findings should the nurse identify as the pri a nurse is assessing a client who is 4 hr postpartum following a vaginal delivery which of the following findings should the nurse identify as the pri
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Nursing Elites

ATI RN

ATI Maternal Newborn Proctored Exam 2023

1. A client who is 4 hours postpartum following a vaginal delivery is being assessed by a nurse. Which of the following findings should the nurse identify as the priority?

Correct answer: Saturated perineal pad in 30 minutes

Rationale: In a client who is 4 hours postpartum, a saturated perineal pad within 30 minutes is a priority finding as it may indicate excessive postpartum bleeding (hemorrhage), which requires immediate intervention to prevent further complications such as hypovolemic shock. Deep tendon reflexes being 4+ is within normal limits postpartum. The fundus at the level of the umbilicus is an expected finding at this time frame, indicating proper involution of the uterus. Approximated edges of an episiotomy suggest proper healing.

2. When teaching a client with a prescription for Phenytoin, which of the following instructions should the nurse include?

Correct answer: C

Rationale: Phenytoin is known to cause gingival hyperplasia, a condition characterized by overgrowth of gum tissue. The nurse should instruct the client to monitor for signs of gingival hyperplasia, such as swollen or bleeding gums. Good oral hygiene practices are essential to prevent or manage this side effect. Choices A, B, and D are incorrect. Phenytoin does not typically cause a mild rash, should be taken with food to reduce gastrointestinal upset, and does not warrant an increase in calcium intake.

3. You are called to your patients room by a family member who voices concern about the patients status. On assessment, you find the patient tachypnic, lethargic, weak, and exhibiting a diminished cognitive ability. You also find 3+ pitting edema. What electrolyte imbalance is the most plausible cause of this patients signs and symptoms?

Correct answer: Hyperchloremia

Rationale:

4. What role does culture play in the development of psychopathology?

Correct answer: B

Rationale: Culture is crucial in understanding the development of psychopathology. It influences beliefs, norms, values, and behaviors, which can significantly impact the manifestation and understanding of psychopathological conditions. Choice A is incorrect because culture does have a substantial impact on psychopathology. Choice C is not as strong as choice B in emphasizing the significance of culture. Choice D is incorrect as culture is one of many factors influencing the onset of psychopathology, not the sole determinant.

5. Who took the position that organisms tend to repeat responses that lead to positive outcomes and tend not to repeat responses that lead to neutral or negative outcomes?

Correct answer: B

Rationale: The correct answer is B.F. Skinner. Skinner proposed the theory of operant conditioning, where behavior is shaped by its consequences. Positive outcomes increase the likelihood of a behavior being repeated, while neutral or negative outcomes decrease it. Sigmund Freud (choice A) is known for his psychoanalytic theory, Carl Rogers (choice C) for person-centered therapy, and Abraham Maslow (choice D) for the hierarchy of needs.

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