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: Elevated blood pressure

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 has an oxygen saturation of 88% on room air. Which action should the nurse take first?

Correct answer: A

Rationale: The priority action for a client with an oxygen saturation of 88% on room air is to initiate oxygen therapy to improve oxygen saturation levels. Oxygen therapy is crucial to address hypoxemia promptly. Placing the client in a high-Fowler's position can also aid in oxygenation, but administering oxygen takes precedence. While notifying the healthcare provider is important, it is a secondary action after ensuring the client's immediate need for oxygen is met. Documenting the finding in the client's medical record is necessary for continuity of care but is not the primary intervention when addressing hypoxemia.

3. Which part of the superego develops from our experiences with rewards for proper behavior and tells us what we should do?

Correct answer: B

Rationale: The correct answer is B, the Ego-ideal. The Ego-ideal is a subsystem of the superego that develops from experiences with rewards for proper behavior. It guides individuals on what they should do, setting standards and ideals for behavior. Choice A, Conscience, represents the part of the superego that focuses on what one should not do, based on experiences with punishment for improper behavior. Choices C and D, regressing back to the anal and oral stages respectively, are irrelevant to the development of the superego's components and are not related to experiences with rewards for proper behavior.

4. During the third stage of labor, __________.

Correct answer: C

Rationale: During the third stage of labor, the correct answer is C, the placenta is delivered. This stage occurs after the baby is born and involves the expulsion of the placenta from the uterus. Choice A is incorrect because the thinning of the cervix to nothing typically occurs during the first stage of labor. Choice B is incorrect as uterine contractions usually begin during the first stage of labor to help with the dilation of the cervix. Choice D is incorrect because the baby is typically born in the second stage of labor, not the third.

5. By which age should the nurse expect that an infant will be able to pull to a standing position?

Correct answer: C

Rationale: Pulling to a standing position typically occurs between 11 to 12 months, marking the progression towards walking.

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