a nurse is assessing a client who is pregnant for preeclampsia which of the following findings should indicate to the nurse that the client requires f
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Nursing Elites

ATI RN

ATI Maternal Newborn Proctored Exam 2023

1. During an assessment, a nurse is evaluating a pregnant client for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

Correct answer: C

Rationale: Preeclampsia is characterized by elevated blood pressure, proteinuria, and sometimes edema. Hypertension is a key sign of preeclampsia, and if present, further evaluation and monitoring are necessary to prevent complications for both the mother and the fetus.

2. 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?

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.

3. A client who experienced a cesarean birth due to dysfunctional labor expresses disappointment for not having a natural childbirth. Which response should the nurse make?

Correct answer: A

Rationale: The correct response is to acknowledge and validate the client's feelings of disappointment. This empathetic approach demonstrates understanding and support for the client's emotional state, fostering a therapeutic nurse-client relationship. Options B, C, and D do not address the client's emotional needs or provide appropriate support in this situation.

4. A newborn is born to a mother with poorly controlled type 2 diabetes. The newborn is macrosomic and presents with respiratory distress syndrome. The most likely cause of the respiratory distress is which of the following?

Correct answer: A

Rationale: The correct answer is hyperinsulinemia. In infants born to mothers with poorly controlled diabetes, the excess glucose crosses the placenta, leading to fetal hyperglycemia. This results in fetal hyperinsulinemia, which in turn can cause macrosomia (large birth weight), increasing the risk of respiratory distress syndrome due to the immature lungs' inability to handle the increased workload. Hyperinsulinemia, not increased deposits of fat, brachial plexus injury, or increased blood viscosity, is the most likely cause of respiratory distress in this scenario.

5. When reviewing the arterial blood gas values for a client, a nurse notes a pH of 7.32, PaCO2 of 48 mm Hg, and HCO3 of 23 mEq/L. What does this indicate about the acid-base balance?

Correct answer: A

Rationale: The given values suggest respiratory acidosis. In respiratory acidosis, the pH is low (<7.35), PaCO2 is high (>45 mm Hg), and the HCO3 is normal or slightly elevated. In this scenario, the low pH (7.32) and high PaCO2 (48 mm Hg) indicate respiratory acidosis, where there is an excess of carbon dioxide in the blood, leading to acidification of the body fluids.

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