ATI detailed answers (150 questions with detailed correct answers) latest solution 2023
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ATI detailed answers ATI detailed answers
Maternal-Child Nursing (Chamberlain University)
1) A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagno...
pg. 1 1 lOMoAR cPSD|10450713 ATI detailed answers ATI detailed answers Maternal -Child Nursing (Chamberlain University) lOMoAR cPSD|10450713 pg. 2 1) A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis? a. Painless red vaginal bleeding i. Rationale: Placenta previa is a condition of pregnancy when the placenta implants in the lower part of the uterus, partly or completely obstructing the cervical os (outlet to the vagina). Bright red, painless vaginal bleeding occurs in the second and third trimester. 2) A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention? a. A newborn who is 12 hr post -delivery and has a temperature of 37.5° C (99.5° F) Rationale: Hyperthermia in the newborn requires immediately intervention. Hyperthermia is typically caused by increased heat production related to sepsis or decreased heat loss 3) A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take? a. Document the findings and continue to monitor the client. b. Rationale: These are expected findings. At 1 hr postpartum, lochia rubra should be intermittent and associated with uterine contractions. The volume of lochia resembles that of a heavy menstrual per iod. Small clots are common. The nurse should document the findings and continue to monitor the client. 4) A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority 5) nursing action? 6) A nurse is caring for a newborn immediately lOMoAR cPSD|10450713 pg. 3 following birth. After assuring a patent airway, what is the priority 7) nursing action? 4. A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action? a. Dry the skin. b. Rationale: The newborn should be thoroughly dried, covered with a warm blanket, placed on the mother’s abdomen, and a cap applied to the newborn’s head to prevent cold stress. The newborn responds to the cooler environment by increasing his respiratory rate, which can lead to respiratory distress. Based on Maslow’s hierarchy of needs, this is the most important nursing action after securing the airway. 5. A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make? a. “It occurs during the first trimester and near the end of the pregnancy.” b. Rationale: Urinary frequency is due to increased bladder sensitivity during the first trimester and recurs near the end of the pregnancy as the enlarging uterus places pressure on the bladder 6. A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse notices she does not have immunity to rubella. Which of the following times should the nurse understand is recommended for rubella immunization? a. Shortly after giving birth Rationale: The rubella immunization should be offered to the client following birth, preferably prior to discharge from the hospital. This prevents the client from contracting rubella during the current or subsequent pregnancies, which would put her fetus at risk for rubella syndrome. 7. A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn? a. Clear the respiratory tract. b. Rationale: Clearing the airway of the infant is the first action the nurse should take immediately following delivery. lOMoAR cPSD|10450713 pg. 4 8. A nurse in a family planning clinic is caring for a 17 -year -old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make? a. "What part of the exam makes you most nervous? b. "Rationale: This therapeutic response recognizes the client's feelings. It also uses the therapeutic technique of clarification to encourage the client to tell the nurse more about her concerns 9. A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord? a. Two arteries and one vein b. Rationale: The vein carried the oxygenated, nutrient -rich blood from the placenta to the fetus, and the two arteries returned the blood to the placenta. 10. A nurse is caring for a client who is considering several methods of contraception. Which of the following methods of contraception should the nurse identify as being most reliable? a. An intrauterine device (IUD) b. Rationale: An IUD is found to have a failure rate of less than 1 in 100 users, which makes it one of the most reliable methods of contraception. 11. A nurse is caring for a newborn and calculating the Apgar score. At 1 min after delivery, the following findings are noted: heart rate of 110/min; slow, weak cry; some flexion of extremities ; grimace in response to suctioning of the nares; body pink in color with blue extremities. Calculate the newborn’s Apgar score. a. 6 points b. Correct Rationale: The Apgar score is 6 out of a possible 10. It is based on 5 signs evaluated at 1 and 5 min after delivery that indicate the physiologic state of the newborn as he transitions from intrauterine life to extrauterine life: heart rate over 100/min = 2; slow, weak cry = 1; some flexion of extremities = 1; grimace in response to suctioning of the nares = 1; body pink in color with blue extremities = 1. A score of 4 to 6 indicates moderate difficulty adjusting to life outside of the womb. 12. A nurse is caring for a client who is 12 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect? a. Fundus firm, at the level of the umbilicus b. Rationale: Within 12 hours after birth, the fundal tone is expected to be firm, and the location is typically palpated midline and at the level of the umbilicus. 13. A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?
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