a nurse is assessing a client who is 12 hr postpartum the clients fundus is two fingerbreadths above the umbilicus deviated to the right of the midlin
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Nursing Elites

ATI LPN

Maternal Newborn ATI Proctored Exam 2023

1. A client who is 12 hours postpartum has a fundus located two fingerbreadths above the umbilicus, deviated to the right of the midline, and less firm than previously noted. Which of the following actions should the nurse take?

Correct answer: B

Rationale: In this scenario, the client's fundus findings indicate a distended bladder, which can lead to uterine atony. Assisting the client to the bathroom to void is essential as a distended bladder can inhibit the uterus from contracting normally. This action can help the uterus contract effectively and prevent complications such as postpartum hemorrhage. Placing the client in a side-lying position, obtaining a prescription for IV oxytocin, or administering methylergonovine are not the priority actions in this situation. Placing the client in a side-lying position might be indicated for fundal displacement, but it is not the priority here. Obtaining a prescription for IV oxytocin and administering methylergonovine are interventions for managing uterine atony, which is not the primary issue in this case; the priority is addressing the distended bladder.

2. A healthcare provider is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification?

Correct answer: D

Rationale: The correct answer is D. Ambulating twice daily is not recommended for a client with severe preeclampsia. Clients with severe preeclampsia are at risk for seizures and should be on bed rest to prevent complications. Ambulation can increase blood pressure and the risk of seizure activity in these clients. Assessing deep tendon reflexes, obtaining a daily weight, and continuous fetal monitoring are all appropriate and important interventions for a client with severe preeclampsia to monitor for signs of worsening condition and fetal well-being.

3. A healthcare professional is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the professional use to help minimize the pain of the procedure for the newborn?

Correct answer: D

Rationale: Placing the newborn skin-to-skin on the mother's chest is an effective technique to significantly decrease the newborn's pain level and anxiety during a heel stick procedure. This approach provides comfort, warmth, and familiarity to the newborn, promoting a sense of security and reducing distress. It is important for the healthcare professional to implement this technique before, during, and after the procedure to optimize pain management and support newborn well-being. The other options, such as applying a cool pack, requesting an IM analgesic prescription, and using a manual lancet, are not appropriate for minimizing pain in a newborn during a heel stick procedure. Applying a cool pack may cause vasoconstriction and increase pain, requesting an IM analgesic for a routine heel stick is excessive, and using a manual lancet without additional comforting measures may not adequately address the newborn's pain and anxiety.

4. A healthcare professional is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. Which of the following medications should the healthcare professional anticipate administering?

Correct answer: C

Rationale: Erythromycin eye ointment is the medication of choice for preventing ophthalmia neonatorum, an eye infection in newborns caused by exposure to gonorrhea or chlamydia during birth. Erythromycin helps prevent the transmission of these bacteria from the mother to the baby during delivery, protecting the newborn's eyes from potential infection. Ofloxacin, Nystatin, and Ceftriaxone are not indicated for preventing ophthalmia neonatorum. Ofloxacin is a fluoroquinolone antibiotic used for treating eye infections in adults, Nystatin is an antifungal medication used for fungal infections, and Ceftriaxone is a cephalosporin antibiotic used for various bacterial infections, but not for preventing ophthalmia neonatorum.

5. A client at 42 weeks of gestation is having an ultrasound. For which of the following conditions should the nurse prepare for an amnioinfusion? (Select all that apply)

Correct answer: A

Rationale: In this scenario, the correct answer is "Oligohydramnios". Oligohydramnios, which refers to low amniotic fluid volume, may necessitate amnioinfusion to address the deficiency. Fetal cord compression is another indication for amnioinfusion as it can help alleviate pressure on the umbilical cord. Hydramnios or polyhydramnios, conversely, involve an excess of amniotic fluid and do not typically require amnioinfusion. Therefore, choices B, C, and D are incorrect in this context.

Similar Questions

A nurse at an antepartum clinic is caring for a client who is at 4 months of gestation. The client reports continued nausea, vomiting, and scant, prune-colored discharge. The client has experienced no weight loss and has a fundal height larger than expected. Which of the following complications should the nurse suspect?
A caregiver is being taught about bottle feeding a newborn. Which of the following statements by the caregiver indicates a need for further instruction?
A client who is at 12 weeks of gestation is reviewing a new prescription of ferrous sulfate. Which of the following statements by the client indicates understanding of the teaching?
A healthcare provider is preparing to administer vitamin K by IM injection to a newborn. The medication should be administered into which of the following muscles?
When assisting a client with breastfeeding, which of the following reflexes will promote the newborn to latch?

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