ATI Maternal Newborn Proctored Exam 2024

ATI Maternal Newborn Proctored Exam 2024 Related

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A nurse is caring for a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure?

  • A. Observe color and consistency of fluid.
  • B. Assess the fetal heart rate pattern.
  • C. Assess the client's temperature.
  • D. Evaluate client for the presence of chills and increased uterine tenderness using palpation.
Correct Answer: B

Rationale: The priority nursing action following an amniotomy (rupture of the amniotic sac) is to assess the fetal heart rate pattern. This is crucial to monitor for any signs of fetal distress or complications that may arise after the procedure. Changes in the fetal heart rate pattern can indicate the need for interventions to ensure the well-being of the fetus. Observing the color and consistency of the amniotic fluid, assessing the client's temperature, and evaluating for the presence of chills and increased uterine tenderness are also important assessments following amniotomy, but assessing the fetal heart rate takes precedence in this situation to ensure the safety of the fetus.

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The nurse suspects that a client has an early sign of ectopic

  • B. Abdominal pain
  • C. Vaginal spotting or light bleeding
  • D. Pelvic pain
Correct Answer: C

Rationale: Vaginal spotting or light bleeding is one of the early signs of an ectopic pregnancy. Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tube. The presence of vaginal spotting or light bleeding may indicate the implantation of the fertilized egg in a location other than the uterus, leading to the suspicion of an ectopic pregnancy. It is essential for the nurse to recognize this early sign and promptly assess the client for further evaluation and intervention to prevent complications such as rupture and severe bleeding that can be life-threatening.

The nurse is preparing a client for an amniocentesis. What is the priority nursing action?

  • A. Verify signed informed consent.
  • B. Administer prescribed analgesics.
  • C. Encourage the client to empty their bladder.
  • D. Position the client in a semi-Fowler's position.
Correct Answer: A

Rationale: Ensuring informed consent is signed is a critical step before an invasive procedure like amniocentesis.

The nurse is monitoring a pregnant client with severe preeclampsia. Which finding requires immediate intervention?

  • A. Blood pressure of 140/90 mmHg.
  • B. Urine output of 30 mL/hr.
  • C. Complaints of headache and blurred vision.
  • D. Weight gain of 1 pound in one week.
Correct Answer: C

Rationale: Headache and blurred vision are signs of worsening preeclampsia, indicating potential eclampsia.

The nurse is caring for a client in the second stage of labor. What assessment indicates that birth is imminent?

  • A. Cervix is dilated to 8 cm.
  • B. Fetal head is crowning.
  • C. Contractions every 3–5 minutes.
  • D. Client reports back pain.
Correct Answer: B

Rationale: Crowning occurs when the fetal head becomes visible at the vaginal opening, indicating that birth is imminent.

Which of the following is a unique risk factor for substance misuse in individuals AFAB?

  • A. Genetic predisposition
  • B. High socioeconomic status
  • C. Regular physical exercise
  • D. History of trauma
Correct Answer: D

Rationale:

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