ATI RN
ATI Maternal Newborn Proctored Exam 2023
1. 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. A client who experienced a cesarean birth 4 hours ago and reports pain
- B. A client who has preeclampsia with a BP of 138/90 mm Hg
- C. A client who experienced a vaginal birth 24 hours ago and reports no bleeding
- D. A client who is scheduled for discharge following a laparoscopic tubal ligation
Correct answer: A
Rationale: The nurse should prioritize seeing the client who experienced a cesarean birth 4 hours ago and reports pain first. Pain assessment and management are crucial post-cesarean birth to ensure the client's comfort and well-being. Immediate attention is needed to address the client's pain and provide appropriate interventions. The other clients may require attention but do not have an immediate postoperative concern like pain following a cesarean birth.
2. 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?
- A. Saturated perineal pad in 30 minutes
- B. Deep tendon reflexes 4+
- C. Fundus at the level of the umbilicus
- D. Approximated edges of episiotomy
Correct answer: A
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.
3. 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. I should limit my carbohydrates to 50% of caloric intake.
- B. I will reduce my exercise schedule to 3 days a week.
- C. I will take my glyburide daily with breakfast.
- D. I know I am at increased risk of developing type 2 diabetes.
Correct answer: B
Rationale: Choice B, 'I will reduce my exercise schedule to 3 days a week,' indicates a need for further teaching. Regular exercise is beneficial in managing gestational diabetes and should not be reduced without proper guidance. Choices A, C, and D demonstrate understanding and appropriate actions in managing gestational diabetes.
4. During the admission assessment of a client at 38 weeks of gestation with severe preeclampsia, what would the nurse expect as a finding?
- A. Tachycardia
- B. Absence of clonus
- C. Polyuria
- D. Report of headache
Correct answer: D
Rationale: Severe preeclampsia is characterized by hypertension and proteinuria after 20 weeks of gestation. Headache is a common symptom in clients with severe preeclampsia due to cerebral edema or vasospasm. Tachycardia (Choice A) is not typically associated with severe preeclampsia. Clonus (Choice B) is a sign of hyperactive reflexes, often seen in clients with severe preeclampsia. Polyuria (Choice C) is not a typical finding in clients with severe preeclampsia.
5. 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.)
- A. Elevate the head of the bed to at least 30�.
- B. Apply restraints if the client becomes agitated.
- C. Administer pantoprazole as prescribed.
- D. Reposition the endotracheal tube to the opposite side of the mouth daily.
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.
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