a nurse is assessing a client who is pregnant for preeclampsia which of the following findings should indicate to the nurse that the client requires f
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Nursing Elites

ATI RN

ATI Maternal Newborn Proctored Exam 2023

1. 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.

2. A client at 11 weeks of gestation reports slight occasional vaginal bleeding over the past 2 weeks. Following an examination, the provider informs the client that the fetus has died, indicating a:

Correct answer: B

Rationale: A missed miscarriage, also known as a silent or delayed miscarriage, occurs when the embryo or fetus has died, but no bleeding or contractions have occurred to expel it from the uterus. In this scenario, the client's experiencing slight occasional vaginal bleeding over the past two weeks indicates a missed miscarriage as the fetus has died, but the body has not recognized the loss or expelled the products of conception.

3. 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?

Correct answer: A

Rationale: Delegating the task of providing a sitz bath to a client with a fourth-degree laceration and who is 2 days postpartum to the assistive personnel (AP) is appropriate. This task involves assisting the client with personal hygiene and comfort measures that can be safely performed by the AP under the supervision and direction of the nurse. Tasks like observing redness on the breast, monitoring vital signs during admission for gestational hypertension, and changing perineal pads may require a higher level of assessment and nursing judgment, making them more appropriate for the nurse to perform.

4. A client is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select one that doesn't apply.)

Correct answer: D

Rationale: Repositioning the endotracheal tube to the opposite side of the mouth daily is not a standard practice in preventing complications in a client receiving positive-pressure mechanical ventilation. This action may disrupt the secure placement of the endotracheal tube and increase the risk of complications. Elevating the head of the bed to at least 30� helps prevent aspiration and ventilator-associated pneumonia. Applying restraints if the client becomes agitated helps maintain the safety of the client by preventing self-extubation or accidental dislodgement of tubes. Administering pantoprazole as prescribed helps prevent stress ulcers, a common complication in critically ill patients on mechanical ventilation.

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

Correct answer: D

Rationale:

Similar Questions

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 with acute respiratory failure (ARF) may present with which of the following manifestations? (Select one that doesn't apply.)
A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22, PaCO2 68 mm Hg, Base excess -2, PaO2 78 mm Hg, Saturation 80%, Bicarbonate 26 mEq/L
During the admission assessment of a client at 38 weeks of gestation with severe preeclampsia, what would the nurse expect as a finding?
When caring for a newborn with macrosomia born to a mother with diabetes mellitus, which newborn complication should the nurse prioritize care for?

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