ATI RN
ATI Maternal Newborn Proctored Exam 2023
1. A client who is 2 hours postpartum following a cesarean birth has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care?
- A. Apply warm, moist heat to the client's lower extremities.
- B. Massage the client's posterior lower legs.
- C. Place pillows under the client's knees when resting in bed.
- D. Have the client ambulate.
Correct answer: D
Rationale: The correct intervention for a client who is 2 hours postpartum following a cesarean birth with a history of thromboembolic disease is to have the client ambulate. Early ambulation is crucial in preventing complications such as deep vein thrombosis in postpartum clients. Applying warm, moist heat, massaging the legs, or placing pillows under the knees do not directly address the risk of thromboembolic disease in this scenario.
2. A newborn's mother is positive for the hepatitis B surface antigen. Which of the following should the infant receive?
- A. Hepatitis B immune globulin at 1 week followed by hepatitis B vaccine monthly for 6 months
- B. Hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen
- C. Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth
- D. Hepatitis B vaccine at 24 hr followed by hepatitis B immune globulin every 12 hr for 3 days
Correct answer: C
Rationale: In the scenario where a newborn's mother is positive for hepatitis B surface antigen, the infant should receive both hepatitis B immune globulin and hepatitis B vaccine within 12 hours of birth. This is crucial to provide passive and active immunity against the Hepatitis B virus. Hepatitis B immune globulin provides immediate protection by giving passive immunity, while the vaccine stimulates active immunity in the infant. Administering both within 12 hours of birth is important to prevent vertical transmission of the virus.
3. A healthcare provider is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the provider immediately?
- A. A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions
- B. A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors
- C. A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes
- D. A client who has a diagnosis of preeclampsia reports epigastric pain and an unresolved headache
Correct answer: D
Rationale: The correct answer is a client who has a diagnosis of preeclampsia reporting epigastric pain and an unresolved headache. These symptoms indicate severe preeclampsia, which requires immediate medical attention due to the potential risks of complications such as HELLP syndrome or eclampsia. The other options describe concerning situations but do not represent immediate life-threatening conditions like those seen in severe preeclampsia.
4. 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.
5. A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?
- A. A client who is at 38 weeks of gestation and reports a cough and fever
- B. A client who has missed a period and reports vaginal spotting
- C. A client who is at 14 weeks of gestation and reports nausea and vomiting
- D. A client who is at 28 weeks of gestation and reports of painless vaginal bleeding
Correct answer: D
Rationale:
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